Long-term Care Facility:

Surveillance of MDRO and Clostridium difficile Infections

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ObjectivesAfter this session, the attendee should be able to:

• Recognize patients with MDRO and/or Clostridium

difficile infections (or colonization)

• Conduct surveillance (track and monitor reports) within

the facility

• Explain the role of data feedback

• Identify best practices during transfer of a patient to

another facility

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Our facility… Yes No Don’t know

1. uses standard definitions (such as McGreer criteria or CDC NHSN definitions) to determine if a resident has an infection

2. reviews provider notes to determine if a resident has an infection

3. maintains a list of residents with healthcare-associated infections in a log book

4. keeps a record of healthcare-associated infections in an electronic spreadsheet or database

5. performs house-wide surveillance of infections among our residents

6. performs targeted surveillance for specific infections among our residents

7. tracks rates of infection over time to identify trends ,e.g., monthly rate, quarterly rate, annual rate

8. creates summary reports (e.g., trends) of healthcare-associated infections

9. reports rates of infections by device days (e.g., # UTIs/1000 urinary catheter days/month)

10. shares infection surveillance data with facility Board members

11. shares infection surveillance data with facility leadership (i.e., CEO, DON, ADON, Medical director)

12. shares infection surveillance data with unit managers

13. shares infection surveillance data with all facility nursing staff

14. shares infection surveillance data with all physicians providing care to residents

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Self-Assessment

LTC Assessment Tool is found at http://www.cdc.gov/HAI/prevent/prevention_tools.html#ltc

Definition of Infection for Surveillance

The following 3 conditions must apply:

• All symptoms must be new or acutely worse

• Non-infectious causes of signs and symptoms

should always be considered before a diagnosis

of infection is made

• Identification of infection should not be based on

a single piece of evidence

4Source: APIC, 1996

Some Infection Prevention and Control Policies and its Impact on Surveillance

• Infection surveillance - either ‘whole-house’ (i.e. all

residents) or ‘targeted’ toward high risk/high

volume…

• Note disease trends

• Report data internally – weekly, monthly, quarterly

and as needed

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Sources of Surveillance Information

• ??

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Sources of Surveillance Information

• Ward rounds / morning report• Laboratory results• Nurse or physician notes• Radiology findings• Referring and other HCF in the region• Facility transfer forms

Monthly Infection Log Exercise

• You will need:– McGeer case definitions– Monthly infection log– Laboratory reports– Daily Unit Census

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Patient 4

• 4/3/2012: Mr. Jerry J is admitted to the hospital with pneumonia

• 4/5/2012: Hospital IP notifies you of the sputum culture result on Mr. Jerry J

Modify your Monthly Infection Log to record this information.

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Patient 4 lab result

Patient 5 Lab Result

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1. Enter the laboratory result for patient # 5. 2. Classify the patient according to McGeer

Case Definition for CDI

• the presence of diarrhea, defined as passage of 3 or more unformed stools in 24 or fewer consecutive hours; AND

• a stool test result positive for the presence of toxigenic C. difficile or its toxins or colonoscopic or histopathologic findings demonstrating pseudomembranous colitis.

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Patient 6 lab result

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1. Record the lab result for patient # 6 on the monthly infection log.2. Classify patients 6-9 according to the CDI definition

Patient 11 Laboratory Result

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Classify Patients 11 and 12• Mr. D (patient 11) has:– Fever– Hematuria– Flank pain– Confusion, loss of appetite

• Mrs. D (patient 12) feels fine• Both have the identical organism in their

urine.1.Classify Mr. D and Mrs. D2.What action should you take?

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Patients 11-12

Patient Case Status - McGeerMr. D UTIMrs. D (Colonized)

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• Treat: symptomatic UTI• Do not treat: asymptomatic bacteriuria

ACTION: notify hospital

Patient 13

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Patient 14

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Infection Rate

Represents infection during a period of time in relation to a unit of population (percent or per n population)

PERCENTAGE OF RESIDENTS WITH INFECTION

= # of infection x 100 = Rate of Infectionave. resident census(for the month)

= 4 CDI on WEST x 100 = 4% of residents had CDI in April 100 residents (on WEST)

Resident-days as a Denominator

• Who records resident-days in your facility?• At the same time each day, the total number

of residents is recorded.• At the end of the month, the total is added up

for the month = resident days.

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Estimation of Infection Rate

INFECTION (INCIDENCE) RATE= Number of xxx infections x 1,000 days

Number of resident days in the month

Rate of CDI on WEST Unit:= 4 x 1,000 = 1.33 CDI per 1000 resident-days

(3000)

Summary of Infection Rates

Disease Unit Cases Population Rate per 1000 resident-days

CDI West 4 3000 1.33

CDI ALL

Influenza North

Influenza ALL

VRE South

VRE ALL

MRSA North

MRSA ALL

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Summary of Infection Rates

Disease Unit Cases Population Rate per 1000 resident-days

CDI West 4 3000 1.33

CDI ALL 4 6000 0.67

Influenza North

Influenza ALL

VRE South

VRE ALL

MRSA North

MRSA ALL

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Summary of Infection Rates

Disease Unit Cases Population Rate per 1000 resident-days

CDI West 4 3000 1.33

CDI ALL 4 6000 0.67

Influenza North 4 2000 2

Influenza ALL 4 6000 0.67

VRE South 2 1000 2

VRE ALL 2 6000 0.33

MRSA North 1 2000 0.5

MRSA ALL 1 6000 0.16

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DATA TRENDS

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Questions

1. What action should you take, given these data?–

2. When should you take this action?–

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Questions

1. What action should you take, given these data?– Begin control measures– Outbreaks should be reported to the LHD

2. When should you take this action?– Control measures should be initiated ASAP– Outbreaks should be reported immediately

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http://www.dhhr.wv.gov/oeps/disease/ob/Pages/default.aspx

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Data Feedback Exercise Findings and Conclusions

Feedback means sharing the CDI data in the previous graph with important people in your Long Term Care Facility:

1.Housekeeping2.Medical Director3.Quality Improvement Committee4.West nursing staff

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EVALUATE YOUR PATIENT TRANSFER FORM TO ASSURE NOTIFICATION OF FACILITIES WHEN TRANSFERRING A PATIENT WITH CDI / MDRO

Homework

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Found at

http://www.cdc.gov/HAI/prevent/prevention_tools.html#ltc

Conclusions

• We have learned– How to get surveillance information– How to review laboratory slips and define cases– How to record cases systematically– How to calculate infection rates– How to feed back surveillance data– Some ideas for sharing information between

facilities• Interfacility transfer forms

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For Further Information

• www.dide.wv.gov– ‘outbreaks’• Outbreak toolkits

– ‘healthcare associated infections’

• http://www.cdc.gov/hai/ • http://www.apic.org/

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