2019 NHSN LTCF Training – Infection Surveillance in LTC


>>Good morning everyone.>>Good morning.>>Everyone does not have the
benefit of being tall as Dan, so I’m going to lower
the podium a little bit. I feel like I am peering
over the monitors. So, welcome to Atlanta
and welcome to CDC. I appreciate you
bearing with the humidity and the traffic in
order to get here. We didn’t anticipate the
congestion in the front, so we had to make some
modifications to our agenda. I think we’re still on task
there honestly, which is great. My name is Jeneita Bell. I’m the team lead for the
long-term care facility component of NHSN, and you
will hear a little bit from me and then my colleague Dr.
Nicola Thompson before we dive into the training material. We just want to make sure that we optimize the
time we have with you. We’re very appreciative of
the time and the resources that you expended
being here with us. As such we have a packed
agenda, so we’re just going to give you some
background information to help establish the
importance of reporting to NHSN. We’ll also let you know
about some other activities that we’re engaged in, in
order to supplement the data that we receive from NHSN. So today I’ll talk
about the burden of healthcare-associated
infections in long-term care or HAIs in long-term care, challenges affecting
nursing homes, also other healthcare settings
in long-term care, strategies to overcome those challenges. Why do surveillance? Just kind of piggy-back
after Dr. Pollock’s comments from earlier today, and
give you a brief overview of the annual training so
you know what to expect for the remainder of the week. So first I’d like to start off by discussing nursing home
infection burden estimates that are commonly cited
in the literature. According to Strausbaugh
and Joseph, there are 1.64 to 3.83 million infections
annually in nursing homes. Herzig and her colleagues
found that in the year 2013, there were 1.13 to 2.68
million infections. Now when I put this slide
together I hesitated a little bit because it’s almost like
comparing apples and oranges. The first estimate is
pretty much an incidence. It tells you what happens
annually in nursing homes where the second
one is prevalence, so it tells you what has
happened in the year 2013, but this is some of the
best data that we have and I apologize if you practice in a setting other
than nursing homes. I don’t have much
information on that, but nursing homes pretty
much it’s a good example to discuss the topics that I’m
going to share with you today. But I’m going to share a
little bit of information about how they conducted
the studies to derive these estimates. I promise I won’t share too many
details, because I don’t want to bore you to death at the
very first top of the morning, but I think it’s important to understand what the
limitations are in these studies so that you will then also
understand why it’s so important for us to report to NHSN and
participate in improving data. So Strausbaugh looked at
12 studies from the 1970s and the 1990s and
estimated that there are 1.8 to 13.5 infections per
1,000 resident-care days in long-term care facilities. Notice the term long-term care
facilities, but they wanted to look at nursing homes
and so they extrapolated from that estimate and looked at
estimate rates, incident rates for common infections
in nursing homes. Some of the usual
suspects you might expect like urinary tract infections and respiratory tract
infections, and derived an estimate
from those and determined that there are 0.98 to 7.38
million infections annually in nursing homes. Now they published that
data a while ago. After they had published
that there are other studies that came about that
had better design and more representative
facilities, and so they took the
data from those studies and revised their estimates and
determined that there are 1.64 to 3.83 million infections
annually in nursing homes. Now, is anyone confused about what the methodology
may have been in order to derive those estimates? Don’t be shy. As you can see, my
hand is also raised. The methodology that they
used wasn’t quite clear, but you gain more
confidence in what they did when you look at their results. Here you can look on the
left-hand side of the figure and you see that they
looked at bacteremia, UTIs, skin and soft tissue
infections, gastroenteritis, and lower respiratory
tract infections, and they determined
an incidence rate range, and that’s what the dumbbells
represent here on this slide, and they found that lower
respiratory tract infections have the highest estimated
incidence rate per 1,000 resident-days, which
is not too surprising. It’s something you may
expect on your own. Herzig and her colleagues, they
looked at the minimum data set, or MDS, 3.0 for 2013 quarter 4. They used routinely
scheduled assessments, excluding admission
assessments because they wanted to make sure the
infections they included in their estimate was nursing
home onset and not present on admission, meaning
that the person came in with an infection, and they
then evaluate the MDS infection items they had available, such as multidrug-resistant
organisms, pneumonia, septicemia, UTI,
and wound infection. You notice that gastroenteritis
is not included, because they did not have that infection item
available to them. They looked at – they determine
their prevalence using a 7-day look-back period, and for UTI
they use a 30-day look-back period, and here’s
what they found. They determined that
in 2013 pneumonia and UTI were the most commonly
reported infections among all resident assessments. So for example, among all
those assessments 2.1% included pneumonia during a
7-day look-back period, and 5.6% of the assessments
included UTI for a 30-day look-back period. You notice I keep emphasizing
the 7-day and the 30-day because the number look small. At first you look at
it and you can say, well that’s not too impressive,
but if you figure the time in, the 7 days, you know
2.1% is pretty prevalent. So to add a little icing to
the cake, I included the Office of the Inspector General
report that was published in 2014, and the Office of the Inspector
General looked at adverse events in skilled nursing facilities
among Medicare beneficiaries that were discharged during
the month of August in 2011, and they determined
that events related to infections were responsible
for 26% in adverse events with pneumonia, respiratory
tract infections, surgical site infections,
catheter associated UTIs, and Clostridium difficile
infection being some of the most common. Now hopefully while explaining
these different studies you probably, maybe you had
some time to kind of think about what some of the
limitations may be, and so here on this slide I
just give a brief overview. This may not be applicable
to every study that I just described,
but just some things that we need to consider. The estimates are based on
a small number of residents, and that becomes
important when you think about representativeness. You want to know whether or not these data are actually
applicable to the residents that you see in your
own healthcare facility. It also applies to
the geographic location. I think we can all
probably safely hypothesize that a facility in
California may not be the same as a facility in Michigan, and
therefore the data that applies to a facility in California
may not be applicable to you in Michigan. So again, we’re talking about
representativeness and ability to generalize the data to
where you currently practice. Also, standard infection
definitions are not used. I can pretty much guarantee
that the definitions are used for the infections they
reported data on differ between all three studies
that I mentioned to you. Even them all in the
Herzig study and the Office of the Inspector General report,
although they use MDS data, if the year was different,
the definition for the infection may
have been different, and that becomes important
because you know over time when you make comparisons
you want to know that you’re counting
the same thing. And also, you want to
know what the trends of infection are over time. You don’t know that when
I provide you just a burden estimate. I mean, do you feel wiser now that I’ve given you some
burden estimates about how to prevent infections
in your facilities? Well probably not, because
several key questions haven’t been answered, and
that’s the benefit of monitoring trends over time. You know, you don’t know
how many new infections are occurring from the
estimate I provided you. You don’t know what rates of
infections are problematic, whether the problem
is worsening, or is it getting better? So for me, in order to
answer those questions, we have to have improved
national data. It’s needed to inform
prevention, and I categorize those
questions as a who, what, when, where, and how. For example, who is
disproportionately affected and most at risk for
infection; for any infection? What infection type is
the most problematic? Where should we focus
our efforts? Is the problem new or was
it increasing over time? Is there a geographic region or specific facility type
that’s most adversely affected? That becomes important
even at a national level, and then if you identify
something, how do you know whether or
not you made a difference if you don’t know what things
had been happening over time? So before we dive in and
try to solve this problem, I just at least want to
acknowledge some challenges that affect nursing homes and
in long-term care in general. For example, in the year 2013, there were over 35 million
hospital discharges, and of those discharges 22%, or 8 million inpatients
were discharged to a postacute setting,
and of those 8 million, 9% went to a skilled
nursing facility. You know, if you
roughly estimate that’s about 1 million, and
that was in 2013. I expect that has
increased over time. And why would I expect that? Well, because of
the silver tsunami. Have anyone heard of
the silver tsunami? Anybody? Raise your hand. All right, just only
a few people. I think the first
time I mentioned it to my team, I think people
thought I made that up, and I promise you
I’m not that clever. It’s a term that was
coined several years ago, and it’s used as a metaphor to describe the growing
older, adult populations. So over time the older,
adult population is expected to continue to grow and [inaudible]
and the baby boomer population, thank you, [laughter]
and you know it’s hard because the term tsunami almost
implies older adults are a danger or something to society, but in actuality it
has some implications. So let’s talk about that. The census bureau estimates
that in the year 2050, the population aged 65 and older
is projected to be 83.7 million. That’s almost double
the population of 43.1 million in 2012. Also, for the first
time in U.S. history, older adults are projected
to outnumber children by the year 2035, and that’s
really not that far from now. You’ll see the older adults
65 and older are represented by the green or the teal line
and bar graph, while children under 18 is represented
by the orange, and you see approximately
at the year 2035 where the coin flips
a little bit where older adults
represent a larger proportion of the population compared
to children under 18. Well what else do we know about older adults;
adults older than 65? The majority of long-term
care residents were 65 and over in 2011 and 2012. Now this data I acquired
from the National Center for Health Statistics. It’s a bit dated,
but I’m pretty sure that the statistic is
constant over time, and you probably all can attest
to that, especially if you work in a long-term care setting. You know that most of your
residents are 65 and older. Well what else do we know? We know that long-term care
residents have a higher risk of infection for a number of
reasons, and some of them are because of they have
functional impairment, the co-morbid conditions,
frequent hospitalizations, and frequent exposure
to antibiotics. It makes them, you
know susceptible to particular infections
as described by Dr. Pollock earlier. So why do I mention
all this data? Well, all this information
I provided to you is to help you understand what
some of the implications are. You may have been able to
hypothesize some on your own, and these are some
of my hypotheses is that as older adults increase,
you know in the population over time, and then they become
more dependent upon long-term care facilities, and
they already have this predisposed risk. There will be an
increase in acute care and long-term care facility
volumes, increase in demand on health system resources, increase in healthcare
transitions as people move from the community to the
hospital, or from the hospital to the nursing home,
or nursing home to the hospital,
so on and so forth. And all of that together can be
a threat to healthcare quality and infection prevention
and control. I mean, if you think
about the infrastructure that we currently have,
can we handle this? Even you see people
as they’re admitted, the acuity of the patients or the residents themselves are
increasing, so what do we do as this problem does not go
away and it continues to grow? Now when I started this section,
I talked about challenges, plural, but I only
mentioned one huge example, and I know that this
is only one of many that you are impacted by. But I believe that the
example I just provided to you perfectly illustrates how
there are forces or activities, external to your facility
that you have no control over, but then impacts your ability to
provide care for your residents. So what are some strategies
to overcome the challenge? Well first I think we
need to acknowledge that you don’t work
or exist in a silo. You’re part of a system and you
share patients and residents with other facilities in
your geographic region and sometimes outside of
your geographic regions, because people can cross state
lines in order to get care. You probably know that from
your own personal experience, in addition to your
work experience. I know this makes me think
about my grandmother. For two years she was really
sick, and she was admitted to at least two different
hospitals and three different nursing
homes over that time period, and I know for a fact that that
had an impact on the quality of her care, the continuity
of her care, and probably led or contributed to her
eventual health outcome. Therefore it’s incumbent
upon healthcare facilities to implement a coordinated
approach in order to improve healthcare overall. In fact, colleagues within my
division conducted a study, and they looked at
the interconnectedness of healthcare facilities. They use an example of an antibiotic resistant
bacteria called CRE, and they constructed
this model and looked at 5 years among 10
facilities that share patients. If you look at the grey bar,
it shows the status quo; the things that typically
happen in, you know a facility in transitions of care. They did the status quo that approximately 2,000
patients would get CRE. However, if there was a
coordinated approach implemented where facilities
talk to one another, they involve their
other partners in healthcare whether it
be laboratories, radiology, whomever, and also
include public health, then that number would
be reduced to 400. Only 400 patients would get CRE. So the bottom line is that
more patients get infections when facilities do not work
together, or flip it around and say less patients
will get infections if facilities work together. They concluded their study
remarks with providing a number of recommendations in order to help facilitate a
coordinated approach, but one thing that’s necessary
and we can’t escape is that facilities have to
implement infection control in their own facility in
order for this to work. So despite the coordination
that needs to occur, there still needs to be
something that’s implemented at an individual level
within a facility, and that’s even become
more apparent and there’s more attention
towards that in recent years. If you just look at government
and regulatory activities within recent time,
focusing primarily on long-term care ranging from
the HHS national action plan to prevent HAIs to the CMS
regulatory requirements that were finalized in 2016. Specifically the national
action plan to prevent HAIs, and the language there states that nursing homes
should be encouraged to have HAI infection
surveillance and reporting to NHSN, with a goal
of 5% enrolling in NHSN after five years
following its launch, which was approximately
about 2017. Also nursing homes should
construct a data collection system to support assessment
of healthcare quality, which includes disease
surveillance among other things. And then there’s the reform
requirements for long-term care that were finalized in 2016, which I’m sure you all
are very familiar with. That was a phase approach, but it had a particular section
entitled infection control where it says that we, CMS,
propose to require the facility to have written standards,
policies and procedures for the infection prevention and
control program, including but not limited to a system
of surveillance designed to identify possible
communicable disease or infections. So why do surveillance? Surveillance is kind of
the theme here, right? Dr. Pollock talked about it
a little bit, so I just want to dive into it a
little bit further, because you may wonder
you’re like, why is surveillance mentioned
as a possible solution for improving care or
infection prevention programs within a facility? Well, let’s talk about the term. I think that surveillance
is probably a common term that we use in society, but it’s
often mentioned in a context of security or criminal
justice type thing. Probably many of you,
including myself, you have surveillance
cameras outside your home, or inside your home,
or in your business. People, we all understand. I mean even if you walk
down the street today, there’s probably a
surveillance camera that has caught you
walking down the street. Well, surveillance
you know it allows you to know what’s normal, when
something is no longer normal and may be a cause for
emergency response. Well public health surveillance
it’s the same thing. The formal definition of
public health surveillance is that it’s an ongoing,
systematic collection, analysis, interpretation, and
dissemination of data regarding a
health-related event to reduce mortality, morbidity,
and to improve health. Now I know that’s a mouthful. It’s a lot to grapple with, so I
provide an example for you all. So here I have a few headlines,
and I’m sure that you have seen at least one of them
this year, particularly with the measles outbreak. I think we take for granted
that we, as a public health, understand when an
outbreak happens. You know, it’s posted in the
media and we just take it as truth and say, okay
well there’s outbreak; there’s something
to worry about. But have you ever wondered
how do we even know there is an outbreak? How do we know that, you
know, E. Coli is a problem? You know, don’t people
get E. coli, you know at least once
a year or maybe measles or something like that? Well the answer is surveillance. It’s surveillance because
CDC has systematic, ongoing data collection
system for these diseases and these infections,
so we know what’s normal or what’s called baseline if
you heard that term before, and when things have risen to a
point where there is a red flag, or a cause for concern, or a reason where you
should implement some type of emergency response. And surveillance allows you
to collect data over time, and it’s the cornerstone of what
we do at CDC for this reason, because it enables you to
answer a number of questions like I mentioned before: The
who, what, when, where, and how. Even if you don’t
have the ability through your particular
surveillance system to answer every single question,
it at least provides you with a enough signal so that
you then know where to go dig and where to go looking
further, and you also know is — it helps you know
when the outbreak is over. How would we know when that
measles outbreak is over? Well, again the
answer is surveillance. Well lucky for all of us
and for you, you don’t have to go looking for a
surveillance system. You don’t have to
construct something on your own within
your facility, because you have the National
Healthcare Safety Network available to you. Although the term surveillance
is not in its title, that’s exactly what it is. It’s a surveillance system. It’s the most widely
used HAI tracking system. It’s web-based, as you all
know, and it’s a resource for healthcare facilities to
collect data not just for us at CDC so we can provide
national estimates and publish papers, but
it’s also available for you as a facility, as a
long-term care facility, or an acute care facility, and even including
ambulatory surgical centers where you can identify problems
within your facility itself, measure progress of any prevention
effort you may implement, and then you know
secondarily help comply with quality reporting
requirements. Currently we have over 22,000
facilities reporting into NHSN, and the number keeps ticking
up, which makes NHSN one of the largest surveillance
systems at CDC. So I won’t go through
this in detail because Dan had
already described it, but the long-term care facility
component has three modules, and you’ll learn more about
that today during the training, and you’ll notice that
the healthcare associated infection module only has
UTI under it, and that’s mainly because it’s a placeholder. We expect that we
will continue to grow, so in the near future there will
be additional infections added to that module. So let’s talk about,
specifically, the benefits of NHSN and how does
it fill a gap? Remember the burden
estimates I talked about and those limitations. Well, when you participate
and you report to the respective
modules, it allows you to understand the epidemiology of select infections
within your facility. We also use standard infection
definition, so if you are part of a large corporation, you know
if every facility reporting it to NHSN complies with
the protocols we have, you know you’re measuring
the same things, not apples and oranges. We also allow you to benchmark,
not only at a national data like I — a national level
like I mentioned earlier, but also for your facility. You know what’s happening,
and then again, you know identify
prevention targets, goals, and track prevention progress. So, you know with that
I conclude and say, you know NHSN can provide
the data to inform prevention because again, it
answers those questions and that’s the reason
why it’s the cornerstone of what we do at CDC. But, you know it’s
not use to anyone if no one’s using
it, so we need you. We very much appreciate
you all being here. We want you to spread the word
to your colleagues and others who work in the long-term care
arena or other partners you have about NHSN and the
importance of reporting to it, and you know we’re very
grateful for those of you who have already
bought into the message that I’m giving you today. We recently ended a project
called the CDI Reporting and Reduction Project
where we partner with CMS and the quality improvement
organizations, or QINs-QIOs in the nursing
homes they recruited. How many of you all
participated in this project in one capacity or another? Thank you so much! I mean you all have made
a world of difference. You helped us not only recruit
a number of nursing homes and surpass that HHS national
action plan goal of 5%, but you also helped us
accomplish the objectives of increasing enrollment,
establishing a CDI baseline, and then providing you
with an opportunity to monitor your prevention
outcomes. Just to give an example,
nursing homes enrolled in NHSN in June 2016 were kind of
dispersed across the country. We didn’t have a lot at
the time, and this is right at the beginning of a project
before recruiting really got started. We only had 334 nursing
homes representing about 2% of nursing homes in the
U.S., but at the conclusion of the project in January of
this year, we had so many more. There are over 3,300 nursing
homes enrolled in NHSN, which represents 21% of
facilities throughout the U.S., and that’s again, that
far exceeds the goal that was established or
determined and mentioned in the HHS national action
plans, and it’s enabled us to do a lot, and you’ll
probably hear a little bit more about that during the
training, but I’m very grateful for the work that you committed
and we learned a lot from you, which then enabled us to make
a number of improvements even to this training,
where we’re here today that Courtney had
mentioned this morning. Well, you know increased
participation is great, it’s wonderful, it’s
necessary, but in addition to that we also need quality
data, and that’s one reason that you’re here today and you’ll probably hear
Dr. Anttila say garbage in, garbage out [laughter]. That’s her quote. She may mention that more than once during the
training, because it’s true. If the data we have is not
valid, if it’s not reliable, then there’s not much we can do
with it, and then we’re limited in our ability in order
to fill those gaps in the burden estimates
or those gaps in understanding what’s
necessary in order to build our prevention
practices. So let’s talk about
the annual training. It’s not only for us to give
to you, but also for you all to give to us, and I
think we all come here with our respective skills,
abilities, knowledge, and subject matter expertise,
and hopefully you know even with my example talking
about the interconnectedness of facilities, well there’s
also interconnectedness between you and I. Like we have information that’s
valuable to you and so on and so forth, so it’s
an opportunity for us to link our arms together
and really make a difference. I mean honestly, we all
came to this because not because we wanted to be rich, because if that was the case
we’d probably be somewhere else, right? But we all have a
heart for what we do. We want to improve
healthcare quality. We want to reduce
morbidity and mortality so we can make a difference for
the people that we care for, and then for those
in the future. I mean one day I may need to be
in a long-term care facility, so I need all of you to help
me get this thing right. So this is our NHSN
long-term care team. You have myself and my team,
and you’ve already heard from a couple of
us and you’ll hear from others throughout the week. I just want to at least
introduce you all. I don’t know if I’ve done
this before, but so you know who helped organize
this training, who helps provide materials
for you to access online, and who also answers
your questions. Sometimes the questions may be
relevant to the system itself, but if it’s particular
to a particular protocol or you know a particular module
NHSN long-term care facility component, then it comes
to someone on this team. And so just an overview, in the mornings you’ll
receive some information about the epidemiology, of
course the NHSN protocols, infection prevention, and we
also have some case studies to engage you all to make sure that you’re not just passively
listening; to have discussions with you so you can
inform us as well. In the afternoon we have
some hands on sessions. You’ll learn more about
the capabilities of NHSN. We have the tours that
Courtney mentioned. Also, we have concurrent
activities, so we have busy time
during these two and a half days where
SAMS is here. Courtney mentioned that as well,
and we have NHSN user support who will also provide
some assistance. So if you have basic questions
like how do I change the user of my facility, or you
know my facility got bought by another company;
what do I do now NHSN? They’re here to help
you with that as well. And we have very special guests, the healthcare personnel
safety team. They’re here to talk about influenza vaccination
reporting among your healthcare personnel staff. They will give a
brief presentation, but they’re also
located out in the lobby. They have a table where
they can provide you with some information
and answer your questions and help you get started, because they’re actually
a component of NHSN and then it’s open to any
facility to participate, and I think that topic
is particularly relevant to long-term care, because your
residents are so vulnerable to influenza and it’s important
for staff to be vaccinated. And also we have the CDC store,
so if you want to go back home and you want to brag and
say, hey I went to Atlanta and not only did I go to
Atlanta, I visited CDC and heard about the history of
CDC and went to a tour, then you can get some
branded merchandise and go brag to your friends. So that’s the conclusion
of my remarks. Thank you so much, and I hope
you all enjoy the remainder of the training. [ Applause ]


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