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Long term care top priority for prevention
HHS move underscores infection threat
Long term care (LTC) settings will be the top priority in the next phase of the Department for Health and Human Services (HHS) Action Plan to Prevent Healthcare-Associated Infections (HAIs), a public health official reported recently in Dallas at the annual conference of the Society for Healthcare Epidemiology of America (SHEA).
"I'm pleased to say that this is a national priority," said Nimalie Stone, MD, MS, an LTC infectious disease expert at the Centers for Disease Control and Prevention. Long term care will be the focus of the third phase of the HHS plan, which began with hospitals in 2009 and then added ambulatory care settings.
"There is national recognition that we have to look beyond hospitals," Stone said. "We have to create infrastructure, raise awareness and promote infection prevention in all of these care settings in order to keep patients safe. "
In that regard, the CDC continues to partner with the Centers for Medicare and Medicaid Services (CMS) to enhance infection control measures with conditions of reimbursement, she noted. On the surveillance front, the CDC is moving to include more non-acute care hospitals in its National Healthcare Safety Network (NHSN). A primary aim is to open all lines of communication, particularly when clusters or outbreaks are suspected.
"I would like to put a plea in to promote communication of outbreaks and clusters detected during the time of transitions of care," she told SHEA attendees. "For those of you who are acute care providers when you see a cluster of anything coming into your facility, rather than saying, 'Well, this is present on admission' see if there may be a point source or a common link between those individuals.
"Communicate that to the health department," she continued, "as well as to the transferring facility from whom you received those cases so that we can start to better report and understand the scope of this problem."
Echoing the sentiments of other researchers and speakers at the conference, Stone conceded there is much to improve in the current state of infection prevention along the health care continuum.
"How well are we doing with communication of infection control issues like antibiotic use and MDRO carriage at the time of transitions of care?," she said. "I would say that in general, we are not doing a very good job. However, we are seeing several states taking up this mantle and working on partnering acute and long term care facilities together."
With more national interest, Stone said "regulatory oversight is developing to address infection prevention and control measures in these non-acute care settings. What we are finally starting to come to terms with and recognize is that acute care is `shrinking' in its role in health care delivery. This is [giving] a lot more traction to the importance of focusing beyond the borders of hospitals."
The driving demographics include continuing reductions in hospital length of stay, particularly among elderly people who may be discharged back to LTC sites.
"The decreasing length of stay for the last 15 years or so has been by about 25% in all comers," she said. "But in those people over 65 there is almost a 40% reduction in the length of stayfrom almost nine days to 5.5 days. This is a population that typically takes a longer time to recover from acute illness, and may need bridge locations to receive support services until they are ready to go back to the community."
In addition, CMS is fiscally empowering a number of facilities to take post-acute patients. "Ninety percent of the skilled nursing facilities certified in this country now are taking post-acute care patients," Stone said.
As part of that, non-acute facilities are admitting more patients with well established infection risk factors like the presence of central lines, she noted. "We have a very device-exposed population now in these nursing homes," she said. "And we know from data in the VA system that device exposure carries a three-fold increased risk of nursing home associated infections."
At the same time, infection prevention expertise is notoriously limited beyond the hospital, though 40% of LTC sites in one survey said they had a "trained" infection preventionist, Stone said. "I put that 'training' in quotes because that is not CIC [certified in infection control] training," she said. "That's any kind of training they might considerstate based, etcetera. Less than a third of them do the position on a full-time basis, so they're wearing multiple hats. Anyone who has worked in the LTC setting has a feeling for how stretched people doing infection control really are."
The problemand thus the new national priorityis that this lack of expertise and resources is facing an unprecedented wave of multidrug resistant infections, including a nasty lineup of emerging gram negative bacteria.
"You contrast that [limitation] with this highly complex and growing post-acute care population that they are serving, and you have to worry about the disconnect between the resources and the resident needs," Stone said.