Vermont's infection prevention network unites long term care, hospitals against MDROs

CDC looking at program as model for other states

By Gary Evans, Executive Editor

As infection control and prevention in long term care settings becomes a national priority, a little state may provide some key answers to a big problem: the spread of multidrug resistant organisms (MDROs) across the healthcare continuum. Vermont is on the leading edge of states that are establishing infection prevention collaboratives linking hospitals and long term care facilities.

Patsy Tassler Kelso"It is important to include long term care because you can't just fight infections in one setting — patients move around," says Patsy Tassler Kelso, PhD, epidemiologist for infectious diseases at the state department of health in Burlington, and one of the leaders of the Vermont MDRO Prevention Collaborative

Indeed, they don't call them "health care" -associated infections (HAIs) for nothing, particularly when many patients who would have remained in hospitals in the past now are under care in nursing homes. As we recently reported in Hospital Infection Control & Prevention, public health officials and infection preventionists are alarmed as methicillin-resistant Staphylococcus aureus (MSRA), Clostridium difficile, and a host of emerging gram negative bacterial infections threaten patients and residents as they move among and between acute and long term care settings.

Nimalie StoneThus the pressing need for collaboratives like the one in Vermont, which has enacted its program in partnership with the Centers for Disease Control & Prevention. The Vermont collaborative is "absolutely a strategy that we would like to see continue to be adopted in communities," says Nimalie Stone, MD, MS, a CDC medical epidemiologist specializing in long term care issues. "Healthcare delivery is being pushed into these different settings, patients and residents are moving so much between acute care and long term care. We really want to have a more global approach at a community level to address the problems of HAIs and multidrug resistance because they are manifesting across the continuum of care."

Such collaboratives bring hospitals and nursing homes together in an effort to get front-line staff to share ideas, and particularly to bring acute care infection prevention experience into long term care settings, explains Kelso.

An eye-opening walkthrough

"One of the biggest things that has come out of the project so far in the first six months is communication between facilities," she says. "One of the most telling things was when a [hospital] infection preventionist did a walkthrough at a nearby long term care facility. It was the first time [the IP] had set foot in the facility. Just from walking around, she noticed things like they were using inappropriate dilutions and cotton cloths inappropriately for environmental cleaning."

An easy fix? Not exactly, as it turns out that many long term care settings in Vermont contract out environmental services. "The long term care staff didn't even realize that was going on and when they tried to address that they ran into all sorts of hurdles because it is not even staff that are employed by the facility," Kelso says.

Such cautionary tales and anecdotes may prove instructive as other states contemplate similar collaboratives. However, reams of statistically significant data may prove more elusive, as Vermont has only 14 hospitals — half of them small critical access facilities. The collaborative is comprised of every Vermont hospital — along with one hospital across the border in New Hampshire — and 31 of the state's 40 skilled nursing facilities. A key advantage to using a small state for such a pilot project is that the collaborative could be formed fairly painlessly, but the downside is the numbers generated are understandably small in terms of statistical power.

"We are not seeing a lot of infections, but I think that is really because the volume of patients is so low," Kelso says. "We recognize that it is going to take some time before we can measure any changes in our infection rates."

The participating facilities have been grouped into 13 healthcare "clusters," each comprised of a least one hospital and the local long term care facilities that use that hospital's lab. The idea is that since these facilities care for the same communities, they can address MDROs together through such strategies as:

  • Active identification and specific management for patients carrying MDROs.
  • Use of standardized communication about patients carrying MDROs as they move among facilities.
  • Minimizing use of devices and antibiotics that can increase MDRO risk.
  • Enhancing infection prevention activities.

Each cluster decides which interventions are feasible in their facilities and works together on implementation, Kelso explains. The year-long collaborative was formally launched in September of last year, with four full-day learning sessions slated over time to allow recurrent face-to-face meetings.

"The third one is happening Friday (May 20) and we hope to continue the in-person meetings going forward," she tells HIC. "We are focusing now on antibiotic stewardship and protocols to prevent urinary tract infections (UTIs) at the facilities."

NHSN expanding to include LTC

The state collaborative is also among the first trying to set up electronic data reporting from long term care facilities to the CDC's National Healthcare Safety Network (NHSN) surveillance system. "We are working on the technical challenges with that, and it is going to be something that hopefully helps make this work sustainable," Kelso says.

The expected eventual expansion of the NHSN to include infections in long term care would be the first true national surveillance system, as infection estimates and mortality figures are typically based on extrapolations of study data. It doesn't take state-of-the-art surveillance, however, to get the oft described picture of a setting in need of more infection control resources, training and personnel.

"The resources available in long term care are very different than those in acute care, where they at least have one FTE devoted to infection control," Kelso says. "In long term care, it's often one hat that a director of nursing or someone else wears, but much less an FTE. They often don't have any specific training in infection control."

Likewise, infection control committees common in hospitals are rare in non-acute settings, so the person scrambling to cover infection control has no in-house source of expertise. The time and staffing constraints have become obvious as the Vermont hospitals and public health officials try to reach their long term care colleagues to discuss infection prevention.

"Just logistically trying to reach someone in the LTC facility is hard," Kelso notes. "Even if you have a time set when you are going to speak to the director of nursing for example, when you make the phone call she may be admitting or discharging a resident because some staff members are out. Or she's pushing the drug cart or something and she just can't speak to you."

Further evidence of the infection control challenge in long term care was found in a baseline infection prevention survey developed by the CDC. Vermont and other states are using the survey to establish baseline levels, and predictably, partial data shared by Kelso showed obvious staffing and training needs.

For example, one survey question assessed the level of infection control training of the person responsible for the program in the long term care facility. "There were 31 responses and zero said they had had someone certified in infection control," Kelso says. "Twenty-three (74%) had no specific infection control training."

Indeed, the recurrent reports of the lack of staff, training and other infection prevention components in long term care have prompted proposed laws in several states.

"There is pending legislation in Illinois to require an infection preventionist in long term care," says Deborah Patterson Burdsall, MSN, RN-BC, CIC, corporate infection preventionist for Lutheran Life Communities, Arlington Heights, IL. "I am very much in favor of it personally. I think that it would give support to get appropriately trained [staff] or at least more training for the people who are responsible for infection prevention in long term care."

Introduced Feb. 4, 2011, Illinois (HB 1096) bill would "require skilled nursing facilities to designate an Infection Prevention and Control Professional to develop and implement policies governing control of infections and communicable diseases. The designated professional would be qualified through education, training, experience, certification, or a combination of these factors." The bill is currently in committee, but given the surge of infection rate reporting laws after a few states put them on the books, it is reasonable to expect other states will attempt legislative solutions in LTC.

"There is a lot of dialogue going on, and personally I think that it is a positive step in increasing professionalism in long term care and making it clear that infection prevention is a specialized body of knowledge," Burdsall says.

Asked if the bill could go so far as to require someone on site with true licensure — certified in infection control (CIC), she says, "I doubt they will go that far in this bill, it does not say that. It is basically an emphasis on training, but I think those are some of the finer points that are being worked out in terms of what it is going to require."

Transfer form improves communication

One of the features of the Vermont collaborative that shows immediate promise for widespread adoption is use of a one-page form to eliminate longstanding communication breakdowns when patients and residents move between acute and long term care. (See form) The form includes the patient/resident's MDRO status and other pertinent information related to infection prevention. Thus, the receiving facility can take appropriate precautions to reduce the risk of transmission. For extra emphasis, Vermont has printed the form on bright orange paper.

"This bright-colored form goes right at the front of the chart now, so communication is much more readily apparent," Kelso says. "Because often when a patient goes back and forth a three-inch thick chart goes with them, and somewhere buried in there on a piece of paper may be information, for example, on carriage of MRSA."

The simplicity of the approach is somewhat analogous to the checklists that have dramatically reduced bloodstream infections during central line insertion. "When you don't have that communication across the continuum you lose some of the information that could help outbreak management," Stone says. "That is a huge benefit of partnering these facilities that share patients with one another. If you create lines of communication and they start working more closely together, patient care will improve because providers will have more knowledge of what they have done in the previous setting as they are taking over the care of that person."

It is also important to relay any new findings back to the other institution, which may be unaware of the source or etiology of the infection. "They may fail to recognize a link with subsequent cases," Stone says. "It is a bidirectional responsibility. You want to make sure the other facility and public health are aware."

One of the first proven models of this kind of approach was a successful effort to prevent vancomycin-resistant enterococci (VRE) in the Siouxland region of Iowa, Nebraska, and South Dakota in the 1990s. The effectiveness of widespread collaboration in eradicating infections was hailed at the time as the results were published in the New England Journal of Medicine.1 One of the key lessons of the paper was the emphasis on communication between facilities about VRE "before patient transfer," but the practice was not widely adopted and now a different, more dangerous set of pathogens are underscoring the same message.

CMS mum, but leads HHS working group

Some observers think the growing involvement of the Centers for Medicare and Medicaid Services (CMS) in HAI prevention will ultimately link such communication to reimbursement, making long term and acute care collaboratives part of the pay-for-performance landscape.

Everything is probably on the table at this point because, as we reported last issue, the long term care setting has been chosen as the top priority in the next phase of the Department for Health and Human Services (HHS) Action Plan to Prevent HAIS. In any case, CMS has essentially fiscally empowered a larger number of facilities to take post-acute patients, as Stone estimates that 90% of skilled nursing facilities nationwide now admit post-acute care patients — many of them with well established infection risk factors like the presence of central lines. 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.

The HHS has formed a multi-representative long term care working group to identify key action items. CMS officials declined to comment for this story, with the agency's press office deferring because the HAI prevention project is an HHS-wide initiative. However, it is telling that CMS representatives from the agency's survey certification group and its office of clinical standards and quality are co-chairing the long term care working group.

The working group has met once and may have finished outlining some of the key issues and interventions in time for a general meeting on the HHS action plan slated for this September, says Stone, a member of the panel. Their task is formidable however, as long term care presents some unique challenges for traditional infection approaches, particularly in the face of increasing acuity of residents/patients.

"One of the first challenges being addressed by this group is the fact that long term care is a fairly heterogeneous setting in terms of the types of facilities and services," she says. For example, a long term care setting could include relatively healthy "long-stay" ambulatory residents, those "bridging" from the hospital back to the community, and others seriously ill or under hospice care. "We may have to develop different strategies to prevent infections in these populations because they have inherently different risks they are bringing to the table," Stone says. "The post-hospital population tends to have more devices or antibiotic exposure and they could be a reservoir to drive transmission and acquisition to the long-stay population. But ultimately, I think if we create this infrastructure and education across the continuum of care it is going to make everyone safer."

Reference

  1. Ostrowsky BE, Trick WE, Sohn AH, et al. The Control of Vancomycin-Resistant Enterococcus in Health Care Facilities in a Region N Engl J Med 2001; 344:1427-1433