CDI prevention: A call to action for
nursing homes
Nimalie Stone, MD, MS
Medical Epidemiologist for LTC
Dialysis and LTC Team
Division of Healthcare Quality Promotion
CT CDI prevention collaborative
April 9, 2014
Presentation objectives



Describe how C. difficile infection (CDI) prevention
fits within the national infection prevention
priorities for nursing homes (NH)
Explore the CDI surveillance and prevention
resources available to NHs
Share success stories from other state-led CDI
prevention programs which engage NHs
Importance of infection prevention
programs in NH

NH residents are vulnerable to infections
 Frailty population with complex medical care needs increases
risk of healthcare-associated infections (HAIs)
 Shared living environment allows for spread of infections

Awareness of serious complications from infections for
NH residents
 Driver of antibiotic use and antibiotic resistant bacteria
 Primary cause of transfers to hospital (30-day readmission)

Heightened expectations for NH infection prevention
 Significant revisions to F441 interpretive guidance in Fall 2009
 F441 citations are among the most frequently identified NH
deficiencies
Challenges for NH infection
prevention programs

Limited time and support for infection prevention
program coordinators
 Most have multiple roles/responsibilities in the facility,
 Rarely receive dedicated training on infection control

Limited guidance for HAI prevention practices
specifically for NH and other long-term care settings
 Current guidelines often focus on hospital practices


Need for standards in use of infection surveillance
definitions and data collection methods by NH
programs
Lack of national HAI prevention benchmarks for NHs
HHS National Action Plan to Prevent
HAIs: LTC Chapter
http://www.hhs.gov/ash/initiatives/hai/actionplan/index.html .
Priorities for infection prevention in
LTC
Priority areas for skilled nursing facilities and nursing
homes:





Promoting enrollment and reporting into the NHSN LTCF
Component
Reporting Clostridium difficile infections (CDI) in NHSN
Reporting Urinary tract infections (UTI) in NHSN
Increasing resident influenza and pneumococcal vaccination
coverage reported in the CMS Minimum Data Set 3.0
Increasing Healthcare Personnel (HCP) influenza vaccination
coverage during each annual influenza season
LTC HAI Work Group Update. Presented at 2012 Progress Towards Eliminating Healthcare-Associated
Infections Meeting, Washington DC. November 27, 2012
National infection
reporting system

CDC managed web-based system designed for
healthcare facility reporting of infections



Uses standardized infection definitions to identify events
Data used by facilities for surveillance and internal
quality improvement
Data used by CDC to establish national benchmarks and
track overall improvement in efforts to prevent
healthcare-associated infections


NHSN use for HAI reporting is part of many state and federal
quality reporting programs for several healthcare settings
Currently NHSN use by long-term care facilities is voluntary
NHSN Long-term care facility
component


NHSN reporting option specifically for LTCFs
165 facilities have enrolled since its launch in Sept 2012
www.cdc.gov/nhsn/ltc
Modules & Events

Healthcare-associated Infection Module
 Urinary tract infection (UTI) events
• Both catheter- and non catheter-associated

Laboratory Identified (Lab-ID) Event Module
 C. difficile infections (CDI)
 Multidrug-resistance Organisms (MDRO)
• Including: Methicillin-resistant Staphylococcus aureus, Vancomycin-
resistant Enterococcus, Resistant E. coli and Klebsiella

Preventions Process Measures Module
 Hand hygiene adherence (observations)
 Gown and glove use adherence (observations)
Priority Area 1: National Healthcare
Safety Network Enrollment




Opportunity:
 Promote a standardized HAI surveillance methodology
 Utilize national reporting infrastructure for LTCFs
 Obtain national NH data on incidence of targeted HAIs
Challenges:
 Lack of experience with NHSN for reporting infections
 Limited NH resources (e.g., staff, IT)
Goal:
10% of certified nursing homes enrolled by 2017*
*proposed new targets for NHSN enrollment – pending HHS review and approval
NHSN SNF/NH users by state, 3-2014
<5
31-50
5-15
51-75
16-30
>75
26 states: 164 facilities;
1 NH from Connecticut
Facility size and resident services

Median bed size: 120 (Range 10 – 815)
<=50 beds
18 (15%)


51-100 beds 101-199 beds >200 beds
22 (18%)
53 (44%)
28 (23%)
Average percent occupancy: ~96%
Percent of facilities providing the following services:
Long-term
General
Nursing
Service
Long-term
Dementia
Service
Skilled
Nursing
Service
95%
68%
87%
Long-term
Ventilator
Psychiatric
Service
Service
31%
26%
Bariatric
Service
Hospice/
Palliative
Service
33%
58%
Facility infection prevention resources

Average staff hours spent each week on infection
prevention and control activities
 Average total hours spent on infection prevention: 17.5 hours
 Average hours spent on surveillance: 9 hours (~50% of total)

Infection prevention average staff hours by facility size
<=50 beds
8.6 hours

51-100 beds 101-199 beds >200 beds
16.1 hours
18.1 hours
24.5 hours
Infection prevention average staff hours by affiliation
Hospital-based
Independent
Multi-facility
organization
12.6 hours
18.4 hours
21.8 hours
Priority Area 2: C. difficile infection

Opportunity:


To track the national incidence of nursing home (NH) associated C.
difficile infections (CDI)
Challenges:


Limited experience field testing validity of positive C. difficile lab
tests as a proxy for infections in long-term care settings
Insufficient data available to set benchmarks and targets

Goal:

Evaluate first 3-5 years of reported data to establish national baselines
C.difficile infection (CDI) in LTC
>64
 CDI is the most common
cause of acute diarrhea in LTC
 NH/SNF residents with
multiple risk factors for
colonization and infection
Antibiotics are a major
driver of C. difficile acquisition
and infection


McDonald LC et al Emerg Infect Dis 2006;
Simor AS, J Am Geratrc Soc. 2010
Fluoroquinolone antibiotics
associated with severe CDI
Longer exposure = higher risk
Nursing homes account for a
substantial burden of healthcare
related CDI


94% health care related
75% of these outside
hospitals
 Nursing home residents
 Patients in community
• Outpatient exposures only
• Recent inpatient exposure

Post-discharge CDI common
 Most potent antibiotics used in
hospitals
 Lasting effect on patients
CDC, MMWR;2012;61: 1-6
Recent hospitalization linked to
nursing home onset CDI

Over 50% of nursing home onset incident CDI cases
occurred within 4 weeks of a hospital discharge
Pawar D. et al, ICHE 2012; 33: 1107-1112
Tracking CDI using positive lab tests

NHSN laboratory identified (Lab-ID) CDI events
 Laboratory cultures used as a proxy for surveillance
 Definitions will match the Lab-ID event criteria being
applied across healthcare settings

This method is based solely on laboratory data and
limited resident admissions/transfer data
 This ONLY includes results of testing performed on residents
while at the facility
 Clinical evaluation of resident is not required, and therefore
this surveillance option is less labor intensive
 Use of diagnostic testing for CDI could influence numbers of
reportable events
Identifying a NHSN CDI LabID Event
Advancing Excellence Infection goal
www.nhqualitycampaign.org
Data for monitoring:
AE CDI data collection tool
AE CDI data collection tool


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Excel spreadsheet
Helps facility to track CDI labevents using the NHSN LTCF
definitions
Includes optional data fields
to capture process measures
 Time from identifying diarrhea
to testing stool
 Time from identifying diarrhea
to starting precautions

Provides graphs/charts as
data is entered
AE CDI data collection tool:
Specimen log
Identifying opportunities for
improvement

Four prevention strategies identified for process
improvement




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Early diagnosis/rapid containment of CDI
Hand hygiene
Environmental cleaning/disinfection
Antibiotic stewardship
Successful implementation of many of these strategies
will reduce spread of other MDROs in the nursing home
in addition to C.diff
Resources for the AE Infection goal

Fact sheets about C. difficile infection prevention
 Consumers; nursing home staff; leadership

Assessment checklists for each of the 4 prevention
strategies with questions assessing
 Knowledge and competency
 Infection prevention policies and infrastructure
 Monitoring practices


Links to websites with tools and resources to help
address gaps identified by the assessment checklists
Resources developed AE working group in partnership
with CDC
 Representing nursing home expertise in infection
prevention, clinical care, and quality improvement
Example assessment checklist


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Early identification
and containment
Yes/No format to
assess current
practices
May identify
opportunities for
new practices
http://www.nhqualitycampaign.org/star_index.aspx?controls=InfectionsImprove
Example assessment checklist cont.
AE CDI data collection tool:
Measuring process improvement
AE CDI data collection tool:
Reporting outcomes


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Provides your
summary CDI data by
month
Based on monthly
resident admission and
average daily census
provide on separate
tab in worksheet
Submit data to AE
website to see your
rates compared with
others in the campaign
What about tracking CDI using NHSN?



The AE data collection
tool will help you
gather all the
important data
needed to report
events into NHSN
Eventually, nursing
homes may enroll and
use NHSN for
reporting, and use AE
tools for prevention
Using AE tools will teach facilities the NHSN surveillance
process while also supporting their internal QI activities
www.cdc.gov/nhsn/ltc/ltc-enroll-steps.html
State successes in NH CDI prevention

Vermont, Sept 2010-ongoing, focus on MDRO/CDI
 Acute care and LTCFs partnered into local “healthcare clusters”
 Developed infrastructure to extract electronic data from acute and
LTCF sharing laboratory services
 Enrolled 75% of VT skilled facilities into NHSN LTCF Component

Massachusetts, July 2012- June 2013, CDI and urinary
tract infections (UTI)  linked by antibiotic use
 31 LTCFs (comparing pre/post-intervention periods)
 28% decrease in urine culture testing; 33% reduction in reported UTIs;
45% reduction in C. difficile infection rate

Kentucky, 2011-ongoing, focus on CDI/UTI
 Improved infection prevention knowledge in NHs -- better diagnosis
and management of UTI
 State surveyors attending infection prevention trainings
 14 NHs enrolled in NHSN LTCF component
For additional infection prevention
resources: CDC LTC website
www.cdc.gov/longtermcare
Benefits to getting involved now

SNF/NHs need to invest in their infection prevention
program activities
 National infrastructure to support HAI surveillance and
prevention programs are available and growing
 State HAI programs are working closely with LTC providers

Activities to reducing CDI will reduce spread of many
infections and improve antibiotic use
 These activities will lead to better resident outcomes; fewer
hospitalizations; and less antibiotic resistance

Engaged nursing homes will be prepared for the future
 Data and performance improvement activities for QAPI
 Familiarity with NHSN enrollment and reporting activities
 Seen as Infection prevention and resident safety champions
Thank you!!
Email: nstone@cdc.gov with
questions/comments
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov
Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion