Role of Infection Control and Prevention Programs in Antimicrobial Stewardship

Role of Infection Control and Prevention Programs in Antimicrobial Stewardship


– [Kate] The main part of my
background and the reason why I wanna get up in front and talk to people is our team has been really hard working. I’m really proud to say
that we’ve been in 152 locations, healthcare
places across Nebraska in the last 30 months and so I feel like we have a very good
pulse of what’s happening with infections prevention
and control programs. And so I feel like
that’s the exciting part that I wanna be able
to show and talk about. So a little icebreaker here for the group. Can I have a show of hands
for any Stranger Things fans in the audience, very good thank you. I was afraid it would be less. So I’m kinda flying my nerd
flag here a little bit. But this is a really
great quote for us today. “Science is neat, but I’m
afraid it’s not very forgiving.” Stewardship is incredibly exciting to me. The science of this
and aiming to get ahead of the problems that we see
everyday, being proactive. This is the reason I came to healthcare. But unfortunately we wanna be proactive, we wanna plan our
efforts, but in infection control and prevention, patient conditions often kind of force us to be reactive. That’s where the science
is pretty unforgiving. And so I’m gonna go out on a limb here and assume, some of you, maybe many of you who work in infection
prevention and control are a little worried
about this trend in being involved in antimicrobial stewardship. Because this is more work, but
we know it needs to be done. And so my role here today is talk about what exactly needs to be done and why we’re really well suited to do this work. So of course we’re gonna
talk about the main objective, just describing
our role, infection prevention and control in antimicrobial stewardship. And so the classic role
of infection prevention and I know that not all
infection prevention is through nurses, I
very much appreciate my medical laboratory
science friends as well. But this little picture spoke
to me because it kind of reminds me of why I became
a nurse and what not. Our classic role of infection prevention is just reducing antimicrobial agents by preventing infections from
occurring in the first place and making every effort
to prevent transmission when those infections do occur. This is for me, working in
infection control for as long as I have, this is what I’ve
been doing for a long time and I feel pretty happy
to say that the main study I’m gonna site several
times in this presentation, this is resonant, it’s
still resonant today that this is our main role in
infection prevention and control. But there is some more coming for us. So the new hospital
standard Joint Commission.. I know many people see
Joint Commission and they’re like, whoa, okay, I’m
not joint commission. But I think this is really
helpful for a couple reasons. Joint Commission is really
good about spelling out how to be compliant with regulation. And so they’re also free
guidelines to pull down and so that’s with ICAP we
often cite joint commission because we think they’re
very easy recommendations to kind of pull down and look at. And in this case, they’re
calling us very specifically by name that we are at that
multi-disciplinary table working on antimicrobial stewardship. And if anybody in
long-term care is feeling lonely and left out, this
medication management standard is written
exactly the same way in both acute care and long-term care. And so we’re gonna talk about regulations in the breakout sessions
with greater detail. But I think this is a nice example because it’s so very clearly calls us by name. Why, sometimes it’s seems
like the joint commission and other places just
love to give infection preventionists kind of
impossible problems to solve. But in this case, I think they’re included for a really good reason. There’s a growing body of literature that shows antimicrobial stewardship programs when implemented alongside
infection control measures are more effective than implementation of antibiotic stewardship alone. So this is a representative
study, what I’ve cited here on the slide, and it
comes for a meta analysis published last year and it
included over 30 studies. It’s acute care only, but
I think that the effect is helpful for both types of environments. Because it analyzed the effect
of antibiotic stewardship program on the incidents of infection and colonization with antibiotic
resistant bacteria and C diff. And so the authors used this quote. They give this as credit
to the Butterfly Effect of hand hygiene and so the Butterfly Effect if anybody is not familiar
with it, it was a coined term not by Kate or the
author’s of the study but a guy Edward Lorenz, and
it’s that that example that a butterfly flapping
its wings in a remote tropical rainforest can
influence the formation of a tornado thousands of miles away. And I think that’s how they’re
likening hand hygiene has these huge effects that we’re just beginning to understand now. And so when we ask how
much more effective is it when we implement these two
types of programs together? Much more effective so
co-implementation with hand hygiene interventions
resulted in a 66% reduction in antibiotic
resistance compared to just a 17% reduction in antibiotic
resistance when antibiotic stewardship was implemented alone. And so that’s why we’re
being called to the table. It’s because we know that our work is very meaningful and
it is very effective. And so the next slide, well what exactly are we being asked to do? This study is super
recent, this has just come out in the last month, MaryLou
Manning and her colleagues just came out in the American Journal of Infection Control, our friends at AJIC. They took this, the core elements
of antimicrobial stewardship and they laid them out how
infection prevention synergistic activities can match up with
each of the core element steps. And so I really encourage
all the infection preventionists in the room
to go and look at this study in totality because
I have taken a great amount of liberty in shortening these
statements into the table. But it’s also a super
practical readable study or position paper that
I think really made me feel more confident about
why we’re being called to the table and the
meaningfulness of that. So the things that
speak most to me on this are the action, tracking,
reporting and education. And those are the step, the core elements that I’m gonna talk most about
in the next couple slides. So before we get too
much into the detail of what we should be doing,
I think it’s interesting to say that AJIC also
had this co-article that talked about what do infection
prevention and control people think they’re doing
in antimicrobial stewardship? They did a study, it’s
again MaryLou Manning and her colleagues but they
used the CDC Core Elements of antimicrobial stewardship
and they designed a survey. They sent it out, it was a
convenient sample but at the same time I think it had
very interesting findings. Only 18% of IPs think that
their role is very well defined which very much
matched up with what I thought coming into the talk,
but respondents indicated that they’re spending on average 5 to 10 hours a month on these activities. And so this is important
because as I’ve been across the state, I can very
strongly tell you that infection prevention and
control people are very much straining under the pressure of what they’re being asked to do. There’s never enough time,
there’s never enough people. And so the authors do a
very nice job of pointing out that in order to ensure
role clarity and prevent our program resources form
being stretched even thinner, these activities need to be identified, defined, quantified and recognized. And so I think again,
I’m gonna tell you about how well suited we are to do this work. But as you’re doing this
work, it’s very important that you define what
you’re doing and you try to track your time with
this because it very much matters and that’s
how we’re going to keep defending our program resources. So in this study, again we’re
talking about the action. And what this paper was recommending is that IPs can influence and support the nursing role in
antimicrobial stewardship. So what’s interesting about
this study is that they ask. They asked leaders in infection
prevention and control what they think about certain things. And I wonder if many
of you kind of identify with these statements,
I know I certainly did. So the bedside RN rule in
antimicrobial stewardship is well defined, not
very many people agree. When a patient has a positive
culture, the bedside nurse can distinguish infection
and colonization. Again very little agreement. Finally, beside nurses
know how to interpret microbiology culture reports. Again, it’s the opinion of
infection prevention and control leaders but not very many people agree that they’re not
competent, that nurses are able to understand those
and interpret them. And so when you take
that and turn it around, what do infection prevention
and control leaders think about infection prevention? So IPs provide stewardship
education and training to bedside nurses, not
very much agreement. However, despite this
being a convenient sample, I thought these numbers were interesting. When a patient has a positive culture infection preventionists can distinguish colonization and contamination. Almost 90% of the respondents said yes, we strongly agree that that’s true. And finally 100% of the
respondents say, they agree that IPs know how to interpret
microbiology culture reports. And so I think that this
is important because we feel like we’re good at this. We feel confident about this
and so with that in mind, would you then say that maybe
we could help other nurses and other people at the bedside interpret things the same way? This makes us better teachers,
so I hope you think yes. So we go back to that table, that I had taken great liberty with, I remind you. And that we’ve talked about action and influencing and
facilitating the nursing role. And the next thing we’re
gonna talk about is tracking. So tracking is one of
our very core elements of infection control and prevention. This is our surveillance
and so this is not a new resource, I took this
straight out of the AJIC text. And pulled these items, nothing
really surprising there. It’s the essential first
step in identifying priority areas for
managing antimicrobial use. We’re talking about
doing your surveillance so that it influences your
infection control plan, etc. So this is why we do surveillance. And I think it’s really
important to kind of double down on this concept
because we have been in a lot of places where
the infection preventionist has a facility say, do you think I’m doing enough for MRSA control or
should we be doing more for C diff? And the problem is as an
outsider, I really can’t tell you. You really have to look
at your own data and say are you seeing transmission
within your facility? Are you seeing rates going
up every single year? Those are the things that
tell you you should do more. If you’re finding that
you don’t have an issue, your rates are going down or
they’re not present at all, then you probably don’t
have to do much more. And so surveillance is a really key thing that you can share with your
antimicrobial stewardship team. This is how we prioritize. No facility has the resources
and time to do everything so we really have to be vocal about what we’re seeing as the issues. And in order to do that, we
have to do this day to day work. So again, we’re looking
at routine cultures, new colonization,
infection, we’re measuring per 100 admissions or
per 1,000 patient days. We’re looking at the likely
culprits, your MRSA, VRE, C diff. And in a lot of facilities we’re looking at some of the more scary
Gram negatives as well. We’re tracking ESBL and
carbapenem resistance. And so, keep doing that,
that’s an important thing. We don’t wanna take you away from that. And that data is great
data to share with your antimicrobial stewardship team. So pat yourself on the back,
that’s something we’re doing. This is how we can affect
antimicrobial stewardship. And so I made up this
slide because I think it’s also very important,
if you’re an infection preventionist at a facility
and the way you find out about infections is
that you have to go into every chart and review the chart. Unfortunately, that’s a system
that’s set for disaster. I really wanna encourage
people, surveillance really means that somehow that information is in a pipeline to you. We should really strive
towards people funneling that information to the
infection prevention and control program coordinator or the
person at the facility. We talk a lot about when culture results are resulted to a facility,
can you have a copy of that. Can you have a secondary fax line that you receive a copy of
everyone of those cultures. Do nurses at your facility
know that you need to see a copy, a duplicate report? When people come in
are you part of huddles and things like that, that you understand what’s happening with intake procedures. And really specifically
we need to identify the potentially infectious
people as soon as they hit the facility, we wanna know if
they have isolation needs or infectious status when
they enter the facility. We need to have a
surveillance plan in place so we know what we’re looking for. It’s really not easy for
people to help you to do surveillance if they don’t
know what you’re looking for. So it’s important to
communicate to your colleagues, your administration, etc., this
is the information I need. These are the prioritized
infections and organisms that we’re looking at and
then the notification piece. So there has to be a system
in place that your team or the coordinator of
the program is notified when new antibiotic
resistance is found or that new C diff cases are reported
by the clinical laboratory. And finally it’s not any
good to collect information if we’re not turning it
around to the front line. And so when we talk about
turning it around to the front line, what happens when
you’re not at work? What happens on Saturday
night on Sunday morning? There needs to be
computer alerts and things like that that readily identify people who have infection flags or who
have previously been admitted with infection or types
of colonization in place. Why, I think it’s just
important to kind of go back to this continuous process. We do surveillance so that we can track and report those infections so that we can rapidly respond to transmission. Remember that’s our core duty. Preventing infections from occurring and preventing transmission. And then also that continuum on the bottom is that importance for like funneling the information to you and being a conduit for communication to the
people on the front line. These are very complimentary activities with antimicrobial stewardship. And so I have an audience
participation question here. I’m gonna have a show of hands
for the false answer. The recognition of the
presence of a multi-drug resistant organism in a
facility, for example a CRE or a vancomycin resistant
Staph aureus case is the sole accountability
of the medical laboratory scientists and the prescribers. Raise your hand if you
think that is false. Yeah, very good, very good. The team based approached, that’s how we’re multi-disciplinary. And I would be remiss if
I didn’t touch on some very recent and relevant
guidance on strategy for the use of contact precaution. Again, this is a very common question that we receive on the ICAP team is who should we be putting into contact precautions? I hear this question all the time. I hear such and such facility no longer isolations for MRSA, should
I still isolate for MRSA? And so I think this is
a really great article that I encourage people
to go back, pull it and look at it because this article, I have just a very brief part of it here. But it gives organism specific
guidance for isolation and for discontinuation strategy. It pulls together all the recent evidence and what not and so this
is a very good thing. It’s meant for acute care, but I’m gonna tell you on the next slide about how we can use it in
long-term care as well. And I think the important
thing that I wanna kind of advertise to the IPs in the room is there is a lot with
discontinuing precautions that has been gray for a very long time. And I think this article does a good job of systematizing the
factors that we should consider when we think about
discontinuing isolation. And again, that’s in all
categories, your ESBL patients, your C diff
patients, your MRSA patients. So if I had the whole
30 minutes to talk about contact precautions, I wouldn’t
even scratch the surface. But again, I’m making you
aware of a very good resource. So contact precautions in long-term care. For those of you that are not
working in long-term care, this is a very strict situation. CMS has mandated that we use isolation for only the shortest duration possible and only when it’s very necessary. We don’t want to have people in isolation when it’s not required
and so again, I just want to make you aware
of some good relevant practical information on making choices about strategy at your
facility and that is, if you Google this, this is an AHRQ project. And the lead author on this Deb Bursdall who when she talks about
long-term care, I listen. She’s a very well known
infection preventionist. And so it’s important that
we remember that we have to use a person centered
approach for contact precautions in long-term care,
we use it only when needed. And we take people out using
evidence based guidance. And I think this is a perfect situation where we could flip back to
that acute care guideline and say I’m gonna look
at least at the evidence in acute care and see if I
can apply it to my setting. And also we consider things
that are resident specific. Can they keep their hands clean? Are they keeping their clothing clean? Is it reasonable for us to keep the environment around them clean? That we can do things as the
staff around the patient to reduce the need for that
patient to be restricted. So I come back to my table which I’m probably wearing out your interest of. But we’ve talked about action, we’ve talked about tracking. I think now it’s important
to talk about reporting. And frankly, this is kind of the hardest and most difficult part
of the guideline I think to really talk about and
get your hands around. For the people in the room who do not do infection prevention and
control on a day to day basis, I must tell you this is
a great large vast amount of information we take in
and we have purview over it. And so I took this
little menu from the ICAR survey that we fill out when
we go to all these facilities. And that is there are
domains of infection control that kind of effectively map out all the things that your facility
should be risk assessing, you should kinda have
some programs in place. Just to give you a sense of the topics. So if you’re sitting at the table, if you’re a stewardship
pharmacist or if you are a provider in long-term
care, you look at the table and think what are the
IPs doing, what could they help us with, I think
it’s kind of important to kind of see this menu
of options where you could have a lot of synergy. Just to have an idea of all the things that we’re looking at and
doing in infection control. And the complement to that is the elements of implementation and so
again that ICAR response tool that we’ve been using
for the past 30 months is a really good road map
because we know that we’re not gonna be able to have
really perfect programs where we’re auditing and
training on every single category of infection control. But where we’ve identified
a priority, where we have identified a priority,
this gives up a very good road map of what we should
be considering, okay. And for an example, I’m going to use C diff as the example here. If C diff is a problem at your facility. You see sustained transmission,
you see that people acquire C diff while
they’re at your facility. It feels like a problem to you. Are you providing
training to all healthcare personnel at your facility about C diff? Are you providing that before they provide care to residents or patients? Are you doing training at least annually? Are personnel required
to demonstrate some sort of competency, if you’re
talking about C diff and you’re telling them about
how to clean their hands do they have to demonstrate
to you that they understand when to use an alcohol based
hand rub and when to wash? The process for doing audits is defined. What do we care about, are
we going to look and see if people are using gloves
during patient care? Are we going to make sure that isolation signage is readily available? We need to define what
we’re going to go out and audit to make sure that
our recommendations are actually in practice. The frequency of audits, we’re looking at what should we go out and monitor? How frequently can we do that? That doesn’t have to
be the IP, that can be other staff members are
going out and filling out a checklist and reporting data. Again we’re multi-disciplinary. And what’s the process when
non-adherence is observed? Again, when you’re in a
multidisciplinary team and I think especially
because of the pharmacists, especially because of
the directors of nursing and the providers in the room. When we’re finding that
people are not adhering to what we need them to do,
what’s the practice gonna be? This is a place where your
infection preventionist is gonna need a lot of support from you. And what’s the frequency of feeding back information to staff? And what we give to the front line staff is clearly different than what we give to the providers or the administrators. And so that’s just the example,
C diff was the example I gave there, there’s also really
nice guidelines about MRSA. And I’m giving these
examples because these are the common questions
that we get on the road. And so this slide comes
from the Infection Control and Hospital Epi, the SHEA and IDSA
guideline for the control of MRSA in acute care facilities. And so when we talk about
all those different things that we could be doing, this is a great example of putting them into practice. You don’t have to make this up, it’s already in the guideline. So when we talk about
implementing basic practices. The guideline says the basic practice is conducting an MRSA risk
assessment, educating healthcare personnel about
MRSA, ensuring compliance with hand hygiene
recommendations, ensuring proper cleaning and disinfection of
the environment and equipment, ensuring compliance with
contact precautions, implementing an MRSA monitoring program, creating a line list,
reporting that data back. And so this is a very
systematized guideline where we talk about just
that multi-disciplinary team choosing to control MRSA and
exactly what we’re gonna do. So you don’t have to make these thing ups, the guidelines are out
there and available to you. And on the next slide,
this is the guideline where those MRSA tips I
just gave you came from. There’s an algorithm,
and the idea, I’m really going back to that question,
are we doing enough for MRSA, should I isolate for MRSA. You go to the guideline
and you follow these steps. If you’re seeing that
you’re not controlling MRSA with those basic practices
that we just talked about, we keep going down that algorithm. What do I do next Kate, what do I do next? I mean, people don’t ask me that, but it’s in the guideline,
it’s right there for you. And I’ll point out that
the yellow arrow, way down in the algorithm
where we start talking about MRSA screening,
bathing people with CHG, using mupirocin, those are
pretty far down the line, those aren’t first steps,
those are implementing basic things first and
then working your way down to more specialized,
expensive measures. And so the final audience
participation question, active surveillance testing
for MRSA colonization should be a key programmatic
strategy for all infection prevention programs
that wish to reduce MRSA. Raise your hand if you think
that is false, it’s false. That’s the guideline is
just telling us that the really basic things are
what we should do first. Those are the key programmatic strategies. We don’t worry about surveillance testing until much further down the line. So how Kate you’ve given
me a lot of kind of high up information, what do I do next? And so as you sit on your
multidisciplinary team and you report out the organisms
where you’re seeing trends, where you think there are
problems in your facility. I’m encouraging you to
look at the guidance. And so when I set out to do this talk, I was talking about infection
prevention and control so I went to the APIC
text and I went to AJIC. And so what I’m gonna encourage you to do, what I have learned to
do because of the very good fortune of working
alongside ID physicians and ID pharmacists is dip
your toes into the water of the IDSA guidelines too, look at SHEA. Look at those things
because when we talk about multidisciplinary practices
and being synergistic, it’s really nice when you
look at a guideline together and your recommendations are side by side. And so the guideline I
just talked about for MRSA is one of those guidelines
that talks very much about treatment and all the infection control stuff right next to each other. And the guidelines that
Dr. Horn and Dr. Vivekanandan were talking about, I’m
gonna tantalize you even more with that guideline
to go and look at it. Because I tell you, the IPs in the room, that guideline also
addresses when isolation should be implemented,
how long it should last, whether gloves and gowns should
be worn when caring for your patients, what’s the recommended
hand hygiene method and what’s the role of daily
sporicidal disinfectants. So these are our daily
questions right and it’s nice to see those are right piece and parcel with the treatment guidelines
so when you’re talking about you multidisciplinary meeting we’re all working from the same playbook. And so I encourage you to go
to look at those guidelines. Don’t be afraid to look
at those guidelines. They have lots of stuff
for us infection prevention professionals and them too and also connect with your colleagues. There’s just no substitute
for talking to other people about what they’re doing,
what’s worked for you, being part of your professional societies. And then I’ve listed
some of the really good collaborative organizations on this side. I didn’t’ list them all
and it wasn’t purposeful. But the idea is is when you
work in these collaboratives, whether it’s worth the
hospital association or the quality innovation
network, they’re taking those guidelines and kind of
serving them up for. Do you have a problem with this? Let us show you how to use
the guidelines to do it. And so that’s what the
organizations are there to do. That’s why we have the
meet the experts session today at lunch is to
really talk about where are those resources and how
can I part of those things. So in closing, my summary here,
just what we’ve been talking about, antibiotic stewardship
programs when implemented alongside infection control
measure are more effective than implementation of
antibiotic stewardship by itself. Recent guidance suggest
specific, infections prevention synergistic activities
that relate to the CDC Core Elements for us IPs to look at. And the final thing, I must
encourage you to ensure role clarity and prevent
our resources from really being stretched, we have
to identify, define, and quantify what we’re
doing on these efforts. Definitely dive and do them, but we really wanna keep track of what we’re doing so that we can defend
the time we’re spending. So with that, I will take questions. (audience applause) – [Audience Member] Do
you have any questions? In the meantime I will ask a question. So what, Kate, great talk okay. – [Kate] Thank you. – [Audience Member] What can IPs do to get recognized, is there
something that they can do that their leadership
can get recognize what they’re doing and locate
the needed resources? – [Kate] My recommendation,
the meetings that you’re already holding, in
long-term care you have your QAPI meetings and acute
care hospitals you have your infection control
committee meetings, I would really encourage that you
invite leadership to come to those meetings and hear
about what you’re reporting. Be open to their feedback,
but I would really say just invite them to
hear what you’re doing. – [Audience Member] And
you mention about tracking and tracking also so.
– Tracking also.


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