Externalization of Infection Prevention and Quality Metrics from Acute Care Hospitals (ACH) to Long-term Care (LTC) Scott Stienecker MD FACP FSHEA Medical Director for Epidemiology and Infection Prevention Parkview Health Subtitle: Playing nicely in the sandbox to reduce bugs and readmits
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Externalization of Infection Prevention
and Quality Metrics from Acute Care
Hospitals (ACH) to Long-term Care (LTC)
Scott Stienecker MD FACP FSHEA
Medical Director for Epidemiology and Infection Prevention
Parkview Health
Subtitle: Playing nicely in the sandbox to reduce bugs and readmits
Disclosures/Sources • Medical Director of Epidemiology and Infection
Prevention, Parkview Health System, Vibra Hospital
• CAUTI and CLABSI will move to house-wide as of 1/1/15
• Antibiotic Use will become required
• Increasing reporting of VAE requiring an EMR and electronic surveillance
• VBP
• Process indicators will decrease, outcomes and efficiency indicators will increase
• 1% withhold in 2014 will increase to 2% by 2017
• Mandatory Flu Vaccination for HCW
• IPPS and LTCH PPS update reductions for HAC, VBP and
Readmissions Reductions Programs
• Mandatory reporting of Sepsis Bundles
• Increasing demand for denominators requiring surveillance
programs
VALUE BASED PURCHASING
EXTERNALIZED INFECTION
PREVENTION IN THE ECF
Sarah Y. Won, L. Silvia Munoz-Price, Karen Lolans, Bala Hota, Robert A. Weinstein, Mary K. Hayden, and for the Centers for Disease Control and Prevention
Epicenter Program Emergence and Rapid Regional Spread of Klebsiella pneumoniae Carbapenemase–Producing Enterobacteriaceae Clin Infect Dis. (2011)
53 (6): 532-540
COMMON ECF CONCERNS
ECF, LTACH Concerns
• When to check urines
• Culture on admission
• Maximizing resident freedom—role of the
Individualized Infection Prevention
Program (IIPP)
• When to stop isolation?
• C Diff prevention—role of probiotics
• Expensive antibiotics
Acute Care Hospital concerns about ECFs
• 30 day readmission rates
• Acute Length of Stay (and early transition)
• Transmission of infections contributing to
readmission
• Sepsis
• CHF
• Quality Indicators
LTC Quality Indicators to Consider • Infection Logs, line lists
• Look for gene sequences, not just organisms
• Flu Vaccination Rates
• Staff
• Residents
• TB Conversions
• Patients with Isolation Status Changes
• Med errors
• STAC Rate—Sudden transfer to acute care
• Sepsis
• Hips/Knees—time to independent function
Long Term Care Collaborative
• Hosted at Parkview Quarterly
• Review results of initiatives
• Give all institutions an opportunity to play
in our sandbox
• Forum to determine the “community
standard”
ENVIRONMENTAL TESTING
ATP Testing
• ATP is in all living things, even if killed. It is one of the components of intracellular energy transfer. Cotton fibers will give high readings.
• <30 is considered clean.
• In my tests, 30-150 suggests that the item has been cleaned recently.
• 150-250-fairly dirty—you can do better!
• >250 is filthy!
• Although we typically grow common skin bacteria, if an item isn’t getting cleaned of those germs, think how likely you could spread pathogens, such as C diff, Acinetobacter or MRSA?
This keyboard looks
like it has never been
cleaned!
Nurse on a Stick. Who
cleans it, and How
does this get cleaned?
• ECG machine was filthy
• Hadn’t been cleaned recently (if
ever)
• Vitals machine with high ATP and
high colony counts suggest no
recent cleaning.
• Thermometer was dirty as well.
Phone with MSSA
Cleaned Room
Pt Call Light
ATP: 910
This call light was grossly
contaminated with skin flora
and bodily secretions. It has
coagulase negative staph and
bacilli. The ATP reading
appears indicative of picking
up living microbes on the
surface of the call light.
Hospital—Terminally
Cleaned Patient Room
• Bed rail very clean.
• Grab Bar with very high levels, but also had cotton towels hanging over the rail.
• >20 colonies, not that clean, either. Suspect that there is cotton fiber contamination as well as bacteria present.
• No pathogens recovered.
Tips and Tricks
• Test cleaned rooms to see if EVS is
missing any places
• Orphaned Equipment
• Phones, call buttons, underside of over-
bed tables
• Test dirty rooms to see how far things
spread
• Serratia—Who’s cleaning the pail?
INFECTIONS
ESBL, KPC and CRE (what are they and why do
they matter?)
• Mandatory reportable (possibly) by
September
• Health department Tracking
Figure 1: Distribution of CRE Isolates 2013
and 2014 (N=220)
0
10
20
30
40
50
60
70
80
90
100
Citrobacter
spp.
Enterobacter
spp.
E. coli K.
pneumoniae
Klebsiella spp. Proteus spp. S. marcescens
Nu
mb
er o
f Is
ola
tes
CRE Isolates
2013
2014
From: ISDH—personal communication
Figure 2: Sources Containing CRE isolates
2013 and 2014 (N=220)
0
10
20
30
40
50
60
Urine Wound Blood Respiratory
Nu
mb
er o
f Is
ola
tes
Source
2013
2014
From: ISDH—personal communication
Handouts
• ISDH CRE Submission Form
• CRE Submission Criteria
SEPSIS
February 2015- Sepsis Pilot Update
• 14 in Sepsis Pilot – 50 % participation from intent
• Pilot Participants as of February 2015:
• Ashton Creek
• Lutheran Life Villages – Kendallville
• Heritage Park
• Heritage – FW
• Millers Merry Manor
• Saint Anne’s Home
• Town House • Woodview
• Signature Care
Post Acute Care
Parkview 2014:
All patient discharge
SNF 12.87
PAC 14
For Age >65
SNF 27.6
PAC 29.99
Skilled Nursing Facility Landscape
Sg2
1/3 SNF
patients have a
care-related
adverse event
Ave $15,000/stay
Non-profit SNF
5.4% margin
For profit SNF
Margin 16.1%
Reliance on NPs
Staff shortages
Ave 83% occupancy
ACH SNF typically
at 62% loss
SNF->reducing
LOS, move home
or rehab
TRANSITIONAL CARE PILOT
FOR SEMI-ACUTE PATIENTS
Transitional Care Pilot To provide patients with high acuity and multiple co- morbidities
a smooth transition to Skilled nursing care
• The transitional will be accomplished with remote monitoring
assistance from Parkview eAcute unit.
• Dedicated staff and unit at Ashton Creek.
• Start Date: September 2015
ECF INTERVENTION
PROGRAM
Response Time Month Patients Average
time of
notified to
order in
hours
Numbers
orders written
at time of
notification
(%)
Time from X-
ray
performed to
results in
hours
Time from lab
drawn to
results in
hours
Time for
antibiotic
from order
given in
hours
Time from lab
results to
antibiotics
given in hours
December
2014
26 1.8 10 (38%) 1.6 2.1 8.4 4
January
2015
19 1.5 8 (42%) .78 (47
minutes)
2.9 4.6 2.6
February
2015
16 .75 6 (37%) .88 (53
minutes)
1.4 9.3 1.78
ECF Chart review and focused intervention:
Marked decrease in time to notification, time to X-ray, time from lab draw to
antibiotic.
Time for antibiotic from order to “given” didn’t change, but overall time to antibiotic
did drop
Lactic Acid Tests
Month Patients Lactic Acid
Test
performed
Lactic Acids
results 2 or
greater
December 2014 26 32 11
January
2015
19 15 6
February
2015
16 17 7
Sepsis Long Term Care Data
Note increase in
sepsis cases, but
marked decrease in
septic shock.
CMI dropped. A lot.
December – February 2014
Resident Data N = 61 December 2014 increase in respiratory illness in Fort Wayne
• Parkview volume statistics by Sepsis ICD9 codes stable – no increase in volume
• 3 Hospitalizations • 2 – Hospice
• 1-Cardiac
• Long Term Care Volumes • Sepsis (lowest sepsis ICD9) – increased by 4%
• Sever Sepsis (mid range Sepsis ICD9) decreased by 4%
• Septic Shock(highest sepsis level ICD9) – decreased by 9%
Case Study
• Long term care resident
• 12-26-15 Lactic Acid 4.2 • Protocol started with IV and fluids and antibiotic
• 12-27-15 Lactic Acid 3.6
• 12-29-15 Lactic Acid 1.8
Resident remained at facility
Heart Failure Unit • 6 bed dedicated unit – Heritage Park
• Estimated start date July 2015
• Maintain 80% occupancy
• Parkview Medical Director
• Parkview protocols
• Aggressive post acute discharge Care Advising
Bibliography
• 1. White House Strategy for Combating Antibiotic-