8/8/2011

Objectives
• To describe the current state of infection control
programs in acute care and skilled nursing facilities in
Infection prevention-related Arizona
• To identify challenges acute care and skilled nursing
needs assessment facilities face related to infection control and prevention
• To identify targets for future collaborative HAI activities
Aarikha D’Souza, MPH between acute and skilled nursing facilities
Arizona HAI Coordinator

Continum of care Healthcare-Associated Infections (HAIs)

• Definition:
– Infections that patients/residents accquire during the course of
receiving treatement for other conditions within a healthcare
setting
– Old term- Nosocomial infections

• Categorized by:
– Pathogen: Methicillin Resistant Staphylococcus aureus (MRSA)
– Procedure-associated: Surgical Site Infection (SSI)
– Devide-associated: Catheter-associated urinary tract infection
(CAUTI)

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Regional approach to HAI

HAIs are a regional issue prevention
• Establish communication between facilities sharing
• Transmission between individuals occurs: patients
– Within healthcare facilities – Patient status/ Risk at transfer

– Between healthcare facilities that share
patients/residents
• Multidrug-Resistant Organisms (MDRO)
outbreaks follow the flow of
patient/resident transfer
• Create learning opportunities to share/ learn
– Best practices
– Areas for improvement
• Facilitate shared resources/expertise
– Government- Federal,State and County
– Local Expertise- QIO, APIC
• Focus should be on patients/residents
• Movement away from patient care silos

Impetus for focusing on Impetus for focusing on Skilled

Skilled Nursing facilities Nursing facilities
– Locally – Nationally
• HAI Advisory Committee suggested SNF as a area • CDC, CMS, and HHS
of focus for prevention activity • Developing guidance and tools for longterm care
• Needs assesment identified need for education facilities
andd sharing
h i off iinformation
f ti
• Increasing interest and support of Arizona’s – Ultimate goal
assisted living, nursing home, longterm care and
ambulatory care partners To improve patient/resident outcomes across
• Outbreaks in Skilled Nursing facilities the continum of care

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Purpose of the Needs assessment
• Highlight differences in IP needs and challenges
between the two healthcare sectors
• Identify IP training needs and areas for
improvement
• Ascertain inconsistencies between facility
policies, training needs and infection prevention
challenges
• Serve as baseline information to identify future
priorities in LTC collaboratives
Methods
• Assessment was created in gather baseline information on infection-prevention
related activities in:
– Skilled nursing facilities
– Acute care hospitals
• 35 question survey was emailed via SurveyMonkey to:
– Infection preventionists in acute care facilities
– Staff that perform infection prevention related activities at SNF
• The Arizona HAI Program partnered with several agencies:
–
–
Arizona Hospital and Healthcare Association (AzHA)
Association for Professionals in Infection Pevention (APIC)
– Arizona Healthcare Association (AHCA)
– Health Services Advisory Group (HSAG)
– Arizona Rural Health Office
• Representatives from each agency sent out the needs assessment to their contacts
• Needs assessment was sent out during the first week of June 2011
• Respondents had a month to complete the assessment
• Facilities were contacted if further information was needed for specific questions
• Analyses conducted using SAS
• Results shared at the HAI Strategic Planning Meeting- July 29th 2011

Format Demographics of the Respondents

• A total of 83 responses were received
– 25 from Skilled Nursing Facilities
• Questions were asked regarding the following areas: – 58 responses from Acute care hospitals
– Demographic information on facility
– Personnel involved in Infection Control • Respondents identified themselves as:
– Infection prevention committee
Position in facility Acute care facility Skilled Nursing Facility
– Surveillance- Identifying and tracking infections N(%) N(%)
– Policy development
Infection preventionist 55 (95) 16 (64)
– Trainingg and education of staff
Quality professional 9 (15) 7 (28)
– MDRO management
– Infection prevention Employee health nurse 10 (17) 4 (16)
– Communication with HCF Chief nursing officer 3 (5) 3(12)
– Relationships with the health department Other 2 (3) 13 (52)
•Acute care facility
•Other: 2 respondents identified themselves as risk managers.
• 15/59 respondents fulfilled 2 or more roles
•Skilled Nursing facility
•Other: 6 respondents identified themselves as staff development coordinators, 6 others were DONs

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Basic Facility Information Basic Facility Information

• Facilities represented by needs assessment:
Type of Facility N (%)
• Services performed by facility type:
Acute care hospital 46 (55) Services provided Acute care hospital Skilled Nursing facility
N(%) N(%)
Nursing Home 26 (31)
Wound care 56 (95) 23(92)
Critical access hospital 5 (6)
Foley (urinary) catheter 55 (95) 23(92)
Long-term acute care 3 (4)
hospital (LTAC) Ventilator care 46 (78) 1(4)
Ambulatory surgery center 2 (2) Tracheostomy care 50 (86) 16(64)
Speciality hospital 1 (1) Central lines 55 (95) 22(88)
Skilled nursing rehab 18 (83) 24(96)
• Median number of licensed beds facilities- 120 Custodial care 7 (12) 22 (88)
• Mean- 179 Care for dementia 9 (15) 11(44)
• Range- (6, 662) patients

General Program Information- General Program Information-

Personell involved in Infection Control Personell involved in Infection Control
Acute care hospital Skilled Nursing facility Alternative activities performed by IC staff:

IC staff (Median Number) 1 0.5

IC staff-
Median IC FTE N (%)
Professional Training
Registered Nurse 57 (98) 22(88)
Licensed Practical Nurse - 3(12)
Other 1 (2) -
IC staff- N (%)
Professional Training
Certification in Infection Control 32 (55) 1(4)

APIC trainings 14 (24) 4(16)

No specific infection control training 9 (15) 17(68)

Other 1 (2) 3(12)

Acute care needs assessment

-1 respondent received laboratory training and was not a registered nurse.
- Other- Epidemiology and Biostats (n=1). 2 certification in infection control in the future.

Skilled Nursing facility needs assessment

- 1 respondent had certification in healthcare quality (CPHQ). 1 indicated CIC in future and the other mentioned training, not specified

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General Program Information-

Infection Control Committee
• Is an Infection Control Committee present?
• 84% of SNF
• 98% of AC

• How often does the IC Committee meet? Surveillance activities:

• In both groups, the IC Committee meets monthly- 66% (SNF) and
32% (AC) or quarterly- 19%(SNF) and 46%(AC) Identifying and tracking
• IC committee is comprised of: Nursing Administration, Medical Director,
Quality staff, Environmental Services. infections
• Some SNF reported including dietary and social services.
•Facility Board Members were not included in SNF IC Committees

Surveillance activities
Surveillance activities • Top methods to identify infections by facility
• Systematic and ongoing approach to monitoring type:
illness of patients/residents and staff
– Illness specific baselines need to be
established by a facility
– Track/ identify changes over time
• Rapid identification of illness and exposures can
inform control measures to prevent future illness.

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Surveillance activities Surveillance activities

• Tracking methods by facility type: Report on Infections
Tracking method Acute care hospital N(%) Skilled Nursing Facility N(%) • All SNFs and 97% of ACF respondents create a report on infections to
Electronic database 10 (17) 1 (4) share with facility leadership, nursing staff, unit managers and other
Log/spreadsheet 19 (33) 18(75) essential staff
Use both tracking methods 28 (48) 5(20)
Unknown/Unspecified 1 (2) 1(4)
Infection rates
• 62% respondents perform housewide surveillance in SNFs, with 37% of the respondents also
performing targeted surveillance. Respondents from ACF, usually do either housewide (45%) or
• Infections are typically reported by infection specific rates (39%-SNF) with
targeted surveillance (46%), with 5 respondents performing both types of surveillance. 34% of SNFs also calculating device specific rates. 21% of SNFs do not
• Infections data routinely collected on: calculate infection rates
Skilled Nursing facilities Acute care hospitals • ACFs typically calculate both device and infection specific rates (70%). 4
respondents said they do not calculate rates but report counts.
~ 100% respondents collect data for: CDI, MRSA, VRE, CAUTI, CDI, MRSA, VRE, SSI,
UTI, Respiratory and GI CAUTI, VAP
illness
Surveillance definitions
~ 50% respondents collect data for: CLABSI CLABSI, Respiratory
Illness, Skin and soft • 72% of SNFs and 95% of ACFs use NHSN definitions. Other respondents
tissue infections,
Pneumonia (not VAP) use facility-developed, modification of the NHSN definitions. McGreer
<50% respondents collect data for: VAP UTI, GI Illness definitions were used by SNFs

Policy Development Training and Education

• In both groups, most respondents reported having Top Infection Prevention Training Needs vs. Reported Challenges:
policies to address: Acute care Facilities
Highest
– Standard precautions, Transmission based precautions, Hand Priority • Training Needs • Challenges
hygiene, Aseptic technique, Environmental equipment, • Cleaning and disinfection • Hand hygiene compliance
cleaning/disinfecting of equipment, Bloodborne pathogen of medical equipment • Environmental cleaning
exposure, Safe injection practices etc •Environmental cleaning compliance
•Identification and •Antimicrobial
management of Outbreaks use/stewardship
• The policy that most respondents did not have a protocol •Transfer of patients in and • Providing sufficient
was patient transfer with infections to and from facilties out of facility infection prevention related
training to staff
(64% in ACF and 59% SNF) • Transmission based
precautions compliance

Lowest
Priority

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Training and Education Infection Prevention

Infections of greatest challenge by facility type:
Top Infection Prevention Training Needs vs. Reported Challenges:
Skilled Nursing Facilities
Most challenging Least challenging
Highest
Priority • Training Needs • Challenges Acute care CDI MRSA CAUTI, SSI VAP CLABSI
• Outbreak/cluster identification • Hand hygiene compliance hospitals 31% 19 % 12% 10% 5%
•Transfer of patients in and out • Transmission based Skilled CDI UTI Respiratory VRE CAUTI,
of facility compliance nursing 44% 16% Illnesses 13% VAP and
• Safe injection practices g
• Environmental cleaning facilities 14% wound
• Reporting requirements to HD compliance infections
•Transmission based • Identification of 4% (each)
precautions Outbreak/clusters
• Cleaning and disinfection , CAUTI- Catheter Associated urinary tract infections
Environmental cleaning, BBP CDI- Clostridium difficile infections
training MRSA- Methicillin-resistant Staphylococus aureus
VAP- Ventilator associated pneumonia
VRE- Vancomycin resistant Enterococcus
Lowest
Priority

Communication between facilities

Policies, Education and training needed, Communication of
MDRO status, method of communication
Relationships with the health
department

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Assistance from the health

Role of the health department
department
• The health department works with many types of • Disease reporting
facilites: • Disease and infection prevention-related questions
– Hospitals, nursing homes, assisted living facilities, ambulatory
• Outbreak investigation
surgery centers, dialysis centers, and other healthcare settings
– Help identify the source of the problem and control the spread of
• Local health departments
p ((LHD)) disease
– LHD have built relationships with facilities in their community by: – Collect information on cases
• Receving information on communicable diseases and outbreaks
– Coordinate specimen collection with state lab
• Providing outbreak and infection prevention guidance
• Helping provide education and resources – Provide recommendations/control measures to reduce the risk of
disease

Partnering with the health Relationships with the health

department department
• How to contact
• Comfort level
– Call your local health department in which county Acute care facilities Strongly
agree
Agree Neutral Disagree Strongly
disagree
your facility is located ADHS- Licensing 19% 41% 10% 5% 7%
http://www.azdhs.gov/phs/oids/contacts.htm#L OIDS- state and local 50% 27% 2% - 3%
• When to contact
– Suspect or confirm a reportable communicable Skilled nursing Strongly
agree
Agree Neutral Disagree Strongly
disagree
disease facilities
ADHS- Licensing 30% 43% 9% 9% 9%
– Suspect an outbreak may be occuring
OIDS- state and local 44% 48% 9% - -
– Question regarding a disease related topic

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Relationships with the health Summary of findings

department
Acute care facilities
Reporting an outbreak
Reporting communicable
diseases
Guidance on infection
prevention topic
Assistance on trainings
• Baseline information in profiling similarities & differences between
facilities
– Infection control resources
Skilled Nursing
– Policies and practices
facilities
71%- OIDS 63%- Both agencies
– Perceived greatest challenges
• Training on Infection control topics is needed
77%- OIDS 50% - Both agencies/
OIDS – Facilities are not sure of whom to contact regarding trainings
65% OIDS
65%- 55% OIDS
55%- – While policies are in place
place, training and compliance to policies is
still lacking
45%- OIDS 47%- Unsure of whom to • Although facilities acknowledge having a method of communicating
contact infections, few have policies outlining patient transfer and MDRO
communication. Many expressed education needs in this area

Next steps A Collaborative Effort: Thank You!

• Establish a cross-setting team comprised
Planning Team
of acute and skilled nursing facilities IPs Charlie Chapin
Connie Belden
• Create a subcommittee or working group Diane Kubala
Jessica Rigler
as a prevention collaborative Joe Bestic
LeAnn Swanson
Patty Gray
• Address issues: Shoana Anderson
Sylvia Balesteri
– Reduction in MDRO Toni Lee Aarikha DSouza
Arizona Department of Health Services
– Patient’s MDRO status in patient transfer HAI Program Coordinator
602-364-4561
• Identify training needs to develop training monteia@azdhs.gov
programs for IP staff

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Questions?

Thank-you!

For a detailed summary of the overall results please contact:

Aarikha Dsouz
Email: monteia@azdhs.gov
Phone number: 602-364-4561

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