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Date ArticleType
4/4/2016 Regulatory
Lowdown with Lori: Infection Control

Infection Control – A frequent question I am asked is: “ How do facilities prepare for all the changes coming related to infection control?”  This question comes with some anxiety as our industry is already highly regulated and our focus is stretched with  preparing for payroll based submission of staffing data, changes to quality assurance,  process improvement, and the list goes on. 

I would like to talk a bit about infection control and healthcare associated infections before answering the question mentioned above.  There is something very wrong with going into a healthcare setting to receive treatment for something and acquiring an additional infection along the way or receiving an unnecessary antibiotic for something that can cause unforeseen problems in the future.  HAIs (Healthcare Associated Infections) and the world crisis of antibiotic resistance has CMS’s (Centers for Medicare and Medicade Services) attention, as well as,  healthcare providers across the lines.  Getting a handle on both HAIs and antibiotic resistance is imperative from providers collectively, patient safety perspective, and a cost control perspective. I would be remiss to not mention the effect of the future generations and their treatment of infections depends on how healthcare providers manage antibiotic use today.   With the CMS proposed rule changes related to infection control, post-acute transitions of care and the continued scrutiny of infection control practices during the survey process, it’s time to make change happen but not without understanding top down,  bottom up why change must happen.

Why change is needed.

Bacteria all over the world are outsmarting antibiotics by adapting to the environment and surviving.  Resistant bacteria find vehicles like hands of health care workers, environmental surfaces and in turn, find their way to residents/patients and infect as many as they can. Bacterial infections lead to symptoms such as draining wounds, diarrhea, coughing and sneezing making it even easier for bacteria to find more hosts to infect, especially when the symptoms are not managed when healthcare workers are moving from one resident to another.   Managing residents exhibiting symptoms of infections by implementing isolation (includes set up and removal of equipment), proper use of personal protective equipment, hand hygiene, environmental cleaning and disinfecting procedures, appropriate disinfectant choice and use, disposal or trash, transportation of linen and timely communication is just the start of good infection control practices. 

“Study the past if you would define the future” - Confucius

In 2015, F441, Infection Control was the third most frequently cited federal tag for non-compliance in the state of Indiana during standard surveys and the sixth most cited federal tag in complaint surveys which indicates we have room for improvement regardless of proposed changes in regulation.  The most frequent cause for noncompliance in 2015 were the following:

• Failure of the facility to develop a policy and program related to resident refusal to complete TB screening.
• Infection control tracking data was incomplete and there was not proof of facility analysis to determine patterns and trends of the data that was collected.
• Facility failed to implement an ongoing employee health surveillance program to analyze patterns and trends and implement interventions to assist with decreasing the facility’s infection rates.
• Facility failed to develop and implement an ongoing surveillance monitoring program to prevent the spread of infections.
• Staff failed to follow proper gloving/hand washing during the following procedures:

  1. Dressing Change/Wound Treatment
  2. Incontinence Care
  3. Catheter Care
  4. Passing Medications
  5. Using Glucometer
  6. Giving Insulin
  7. Administering eye drops

Regarding your current and past practice in infection control, answers these questions to guide you in identifying strengths and weakness.

• Do your healthcare employees practice hand hygiene consistently using best practices?
• Do residents, visitors and vendors practice hand hygiene best practices? 
• Does your facility have a policy for isolation and are you setting isolation up correctly each and every time?
• How are isolation rooms cleaned daily and upon discharge/transfer of a resident ?
• Do family’s and visitors adhere to isolation practices 24 hours a day 7 days a week?
• Have you had infection control citations in the last 3 years during survey process?
• How is equipment disinfected and stored?
• How do you determine if a resident placed in contact isolation should be confined to the resident room?

Consider the following scenario. A resident of your nursing facility falls or has a similar accident requiring a transfer to the emergency room. While being treated, emergency department personnel  follow protocol and test the urine of the resident. The urine analysis shows bacteremia. After a few hours, the residence returns to the nursing facility with a diagnosis of a urinary tract infection and an antibiotic to be use for the next 7-10 days. This common scenario contributes to the unnecessary use of antibiotics since the resident was treated for an asymptomatic infection.  Prescribing antibiotics for the treatment of asymptomatic infections overtime is a contributing factor of antibiotic resistant infections and the  emergence of superbugs. 

There are new superbugs on the rise in the US hospitals and other healthcare settings. Those superbugs evade some of the strongest antibiotics, making infections almost untreatable and pretty scary.  CRE (Carbapenem-Resistant Enterobacteriaceae) is the superbug getting the most attention right now.  CRE is in the family of germs that are highly resistant to antibiotics.  Normal gut bacteria such as klebsiellosis S. and Escherichia Coli can become carbapenem-resistant. Healthy people do not usually get CRE infections;  they usually happen to patients in hospitals and nursing homes.  People at greatest risk of contracting CRE are those with multiple medical issues, with impaired/weakened immune systems, on ventilators, with urinary catheters, with placement of intravenous catheters and,  last but not least, with long courses of antibiotics.   Let us face the fact that except for ventilators, high risk people for contracting CRE are the ones we serve every day.

One in twenty-five acute care facilities reported at least one case of hospital acquired CRE infection in 2015.  Most of the people infected with CRE are treated with an older antibiotic called Colistin, which has extreme toxic effects on the kidneys. The use of this drug  can cause more problems than the benefits that it serves.   CRE is deadly since half of those infected with CRE in their bloodstream will die. The spread of CRE,  as well as,  others infections of this type is everyone’s responsibility and we, as healthcare providers, must do what we can to prevent the spread of infection of any kind.

CRE is confirmed by laboratory tests by conducting a rectal swab and , by the way, no one wants to be tested.  Licensed nurses must understand how to read the laboratory test results and complete mandatory timely reporting of CRE infections to the local health department.  The reporting rule has been in place in Indiana since December 2015.  Read more about the laboratory test for CRE by clicking here http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf  and contact your local health department to obtain the link to the electronic CRE Reporting Form.

Because inappropriate antimicrobial use is common in healthcare settings, antimicrobial stewardship programs are needed. These programs assist clinicians in appropriate use of antibiotics including dose, duration, and route of administration. Answer the following questions to guide you in identifying strengths and weakness regarding your management of antibiotic use:

• Do the right people in your organization understand CRE and other Superbugs and the related crisis?
• Do family members and residents understand why antibiotics are not always the answer?
• Are you using the CRE Communication Tool when accepting and transferring residents?
• Do your licensed nurses understand how to read the laboratory results for CRE?
• Are you and others in your organization aware of the mandatory reporting of CRE infections in Indiana and when and where to report?
• Are you prepared to isolate residents having CRE depending on the risk level identified?
• Do you know about other superbugs and how to implement best infection control practices in your facility?
• Do your nurses request physicians to prescribe unnecessary antibiotics for asymptomatic infections?
• Do your physicians prescribe unnecessary antibiotics?
• Do residents remain on antibiotics for longer periods of time than is necessary?
• Do you have residents with unnecessary catheters?

So, the question is:  how do facilities prepare for all the changes related to infection control regulation that are coming sooner rather than later?

“The only man who behaves sensibly is my tailor; he takes my measurements anew every time he sees me, while the rest go on with their old measurements and expect me to fit them” – George Bernard Shaw

Answer: Start with an assessment of where you are today by taking a new measurement and then move forward one step at a time. A written performance improvement plan with established goals, action items and time frames will keep your team focused on the desired outcome.

• Start by completing the CDC Infection Control Assessment Tool used by state health departments to assess infection prevention practices.  Review the assessment with your Interdisciplinary team and identify areas to improve.
• Review your last three surveys to identify historical compliance or non-compliance and readdress areas identified as needing improvement.
• Evaluate your orientation process related to infection control and make adjustments.
• Evaluate your admission prescreening process to ensure information related to CRE and other infections are in place.
• Evaluate your procedures for isolation, ordering of equipment, application of PPE, cleaning of equipment and resident rooms and other areas, and evaluate use and choice of disinfectant.
• Compare your current program to the proposed reform of requirements of participation, infection prevention and control related sections. 
• Review the Core Elements of Antibiotic Stewardship for Nursing Homes released by CDC late last year.
•  Listen to an AHCA member webinar from Dr. Nimalie Stone of the CDC.  Consider taking action on one element at a time to improve Antibiotic Stewardship in your center. 

Stepping back and conducting an assessment and evaluation of your current infection control practice is really stepping up to make the change for a safer resident environment and the greater community at large.
INHCA/INCAL is here to support and assist you in being successful.  Please feel free to contact Lori Davenport, Director of Regulatory Clinical Affairs at ldavenport@ihca.org if you have any questions or need support.