Targeted Infection Prevention (TIP) Study: Rationale and

Targeted Infection Prevention (TIP) Study:
Rationale and Results
Lona Mody, MD, M.Sc
Associate Professor, Division of Geriatric & Palliative Care
Medicine, University of Michigan
Associate Director, GRECC
VA Ann Arbor Healthcare Systems
5.8.2014
OUTLINE
• Emerging and resistant pathogens
– MRSA
– R-GNB
– VRE
• Approach to preventing MDROs in Nursing Homes (NHs)
• TIP Project Overview
CASE STUDY
Mrs. Decker, 87 yrs. old, was admitted to your facility after
hospitalization for a new stroke, delirium, pneumonia and
acute renal failure.
Prior to her hospitalization, she had lived at home with her
husband, but needed 24 hour supervision and assistance in
dressing & bathing because of a history of vascular dementia.
On admission to the hospital, she experienced new left sided
weakness with little recovery during her three weeks of
hospital stay.
CASE: CONT’D
While in acute care, she is found to have swallowing difficulty
and was incontinent of urine. An indwelling urinary catheter was
placed within the first 24 hours and a decision to place a feeding
tube has also made.
She developed a 3 x 3 cm stage 2 pressure ulcer. Considering her
lack of progress in PT, a decision was made to place her in a NH
for long-term care. She is now admitted to your NH. The
questions in her case are:
1. What are the most common infections she can get?
2. What is the risk of colonization with MDRO in a resident like
her?
BURDEN OF INFECTIONS IN NURSING HOMES
• Range widely from 1.4 to 5.2 infections/1000 resident-days
– Single day, point prevalence of 5.2% to 7.6%
– MI NH research consortium:
• No-device: 5.7/1,000 resident-days
• device: 11/1,000 resident-days
• Using this more recent data
– Extrapolated to the 1.5 million adults in U.S. NHs suggests
765,000 to 2.8 million infections/yr
• UTIs, pneumonia, skin and soft tissue, GI infections
CONSEQUENCES OF NH INFECTIONS
• 150,000 – 300,000 transfers to acute care due to infections
• $ 675 million in additional healthcare costs
• Leading cause of mortality and morbidity
• Higher antibiotic use
increased MDROs
IMPACT OF MULTI-DRUG RESISTANT ORGANISMS
(MDROS)
• MDROs: one of the greatest healthcare challenge
• Responsible for
– over 12,000 deaths
– 3.5 billion dollars (in US)
• Prevalence estimates show an increase in MDROs
• New antibiotics
Resistance
• New antibiotics not the only solution, need effective
infection prevention strategies
OUTLINE
• Emerging and resistant pathogens
– MRSA
– R-GNB
– VRE
• Approach to preventing MDROs in Nursing Homes (NHs)
MRSA
• Emerged in acute care in 1960s
• Staphylococcal infections due to MRSA
– 1974: 2%
– 1995: 22%
– 2004: 63%
• Transmission
MRSA: RISK FACTORS IN NHS
• Impaired functional status
• Indwelling devices such as urinary catheters and
feeding tubes
• Prior hospitalization
• Urinary incontinence
• Prior antimicrobial usage
• Wounds and pressure ulcers
MRSA: NATURAL HISTORY IN NHS
• Transfers from acute care
– 2-25% of new residents colonized
• Persist and spread
– Enclosed environment, poor functional status,
presence of devices
– HCW to resident and resident to resident spread
– Serial studies show persistence
MDRO COLONIZATION: MRSA IN NHS
Location
Year
No.
% Colonized
Patients
Comment
St. Louis
1985
74
12
Nasal
LA
1987
170
6.0-7.3
Nasal & wound
Pittsburgh VA-CLC
1986
432
13
Nasal
Vancouver
1989
120
34
Nasal & wound
Ann Arbor
(VA-CLC)
1990
120
23
Nasal & wound
Ann Arbor
(VA-CLC, Co NH)
2000-1
426
15
Nasal & wound
MI NH Research
Consortium
2004-5
200
29 - no device
52 - device
Multiple
anatomic sites
MRSA PERSISTENCE
Mody et al ICHE 2006; 27:2124
MRSA FROM ENVIRONMENTAL CULTURES
MRSA NOT THE ONLY MDRO…
Environmental sampling
MRSA
VRE
R-GNB
C. difficile
Pagers
Stethoscopes
Bedrails
Bed frames
White coats
Bed rails
Sinks
Blood pressure
cuffs
Side table
Ventilator water
Toilet seats
Computer
keyboards
Adapted from: Hebert and Weber,
Infection Prevention and Control in the
Hospital, 2011
OUTLINE
• Emerging and resistant pathogens
– MRSA
– R-GNB
– VRE
• Approach to preventing MDROs in Nursing Homes (NHs)
MDRO COLONIZATION: R-GNB
• Rates exceed MRSA
• Frequent use of antibiotics to treat NH infections
• Resistance in GNB (NH data)
– E. coli:
5-41%
– P. aeruginosa:
27- 67%
– K. pneumoniae:
7-14%
– P. mirabilis:
38-57%
•
•
•
•
Bonomo R, Clin Infect Dis, 2000;31:1414-22
Viray M, Infect Control Hosp Epidemiol 2005;26:56-62
O’fallon et al, Infect Control Hosp Epidemiol 2010
Fisch J, Wang L, Mody L et al, EJCMID & J Clin Micro, 2012
RISK FACTORS FOR R-GNB
•
•
•
•
•
Indwelling devices
Poor functional status
Pressure ulcers/wounds
Quinolone use
Prior hospitalization
QUINOLONE RESISTANCE
• Frequent use to treat NH infections
• Resistance in GNB
– E. coli:
5-41%
– P. aeruginosa:
27- 67%
– K. pneumoniae:
7-14%
– P. mirabilis:
38-57%
• Viray M, Infect Control Hosp Epidemiol 2005;26:56-62
• Bonomo R, Clin Infect Dis, 2000;31:1414-22
• Antibiotic pressure
PERSISTENT CIPR GNB COLONIZATION, BY SPECIES
Number and Name of Species Present
1
2
3
≥4
Preexisting Colonization
(n=27)
New Acquisition
(n=19)
Escherichia coli
10
3
Proteus mirabilis
2
4
Pseudomonas aeruginosa
1
0
Providencia stuartii
2
0
Morganella morganii
1
4
E. coli, P. mirabilis
7
4
E. coli, P. stuartii
0
1
P. mirabilis, P. stuartii
0
1
P. mirabilis, P. fluorescens
1
0
E. coli, P. mirabilis, M. morganii
0
1
E. coli, P. mirabilis, K.
pneumoniae
1
0
1
0
Fisch J, Mody L et al. J Clin Microbiol. 2012; 50:1698-1703
 -LACTAM RESISTANCE IN GNBS
• GNB carry extended spectrum -lactamases (ESBLs)
Outbreaks:
– Massachusetts Chronic Care Facility: 1990
• 25 patients over 4 months
• Ceftazidime use
– Chicago: 1992
• 55 hospitalized patients with CTZ-R
• 31/55 from 8 NHs with CTZ-R
• Point prevalence study in 1 NH: 18/39 CTZ-R GNB
Bonomo R, Clin Infect Dis, 2000;31:1414-22
FUNCTIONAL DISABILITY: R-GNB PREVALENCE
100%
24
80%
% of NH
residents
(no device)
60%
92
83
65
CIP-S
40%
76
20%
0%
8
17
CIP-R
35
1
2
3
4
Functional Status (PSMS): Category 1: Independent to Category 4 = Dependent
Dommeti P, Wang L, Mody L et al, Infect Control Hosp Epid 2011
FUNCTIONAL DISABILITY: RISK FOR MRSA/VRE
CO-COLONIZATION
MRSA/VRE
No Co-colonizationc
co-colonizationb
Characteristic
(n=17)
(n=246)
RR(95%)
Age, mean years
75.9
77.9
1.0(1.0-1.1)
Charlson Comorbidity score, mean
3.2
3.2
0.9(0.8-1.1)
Follow-up Months, mean
6.8
6.6
1.0(0.9-1.2)
Functional disability, mean
26.3
22
1.3 (1.1-1.4)***
Male, No.(%)
13 (76)
103 (42)
3.1(0.9-10.4)
Wound, No.(%)
8 (53)
62 (27)
3.4(1.4-8.6)**
Antibiotics, No.(%)
9 (53)
82 (33)
3.0(1.0-9.1)
Hospitalization, No.(%)
6 (38)
69 (30)
1.6(0.3-9.9)
Long Stayf, No.(%)
7 (41)
97 (39)
1.8(0.5-6.3)
CCS=Charlson’s Comorbidity Score, PSMS=Physical Self Maintenance Score,
Adjusted for repeated measures using GEE, b MRSA/VRE cocolonization modeled as the outcome for each analysis,
* p<0.05, ** p<0.01, *** p<0.001
Flannery E, et al. Clin Infect Dis. 2011; 53:1215-1222
OUTLINE
• Emerging and resistant pathogens
– MRSA
– R-GNB
– VRE
• Approach to preventing MDROs in Nursing Homes (NHs)
VRE (VANCOMYCIN RESISTANT ENTEROCOCCI)
• VRE a relatively recent discovery
– But widespread, esp. in hospitals with significant
mortality and morbidity
• VRE accounts for ~ 30% of ICU isolates of Enterococcus
in the United States
– NHs
– Prevalence varies from 5-20%
COMMONALITY OF RISK FACTORS: MDROS
•
•
•
•
•
Use of indwelling devices
Functional disability
Presence of wounds
Prior antimicrobial usage
Prior hospitalization
• Move from pathogen-based to risk-factor based infection
prevention programs?
OUTLINE
• Emerging and resistant pathogens
– MRSA
– R-GNB
– VRE
• Approach to preventing MDROs in Nursing Homes (NHs)
INFECTION CONTROL STRATEGIES IN NHS
• Progress in NHs infection control
– Guidelines from various national societies
• Immense variations in practice
– Do-nothing to do-everything
– No controlled trials
• Issues to remember
– NHs are not hospitals
– Rehab and socialization critical
• Significant gaps in healthcare workers’ knowledge regarding device
care practices
• Paucity of RCTs to reduce device-associated MDRO colonization and
infections
Mody L et al, J Am Geriatr Soc 2007, Wang L et al, E J Clin Micro 2011, Mody L, Bradley SF, Kauffman C et al, Clin Infect
Dis 2008, Mody L, Saint S, Krein S et al; J Am Geriatr Soc 2010
BACKGROUND
 MDROs common in NHs



indwelling devices increase risk
multi-anatomic site colonization with MDROs frequent
device specific pattern
 Significant gaps in healthcare workers’ knowledge
regarding device care practices
 Paucity of RCTs to reduce device-associated MDRO
colonization and infections
Mody L et al, J Am Geriatr Soc 2007, Wang L et al, E J Clin Micro 2011, Mody L, Bradley SF,
Kauffman C et al, Clin Infect Dis 2008, Mody L, Saint S, Krein S et al; J Am Geriatr Soc 2010
29
TYPES OF INTERVENTIONS STUDIED
• Studies conducted at single NHs have generally
focused on one of four types of interventions
– hand hygiene
• Mody L, ICHE 2003; Schwoen S, AJIC 2011; Chami K, JAMDA 2012
– gown use and contact precaution
• Trick WE, JAGS 2004
– decolonization regimens
• Wendt C, ICHE 2007, Mody L , Bradley SF et al CID 2003, Kauffman CA et al 1993
– infection prevention education
• Baldwin NS, J Hosp Infect 2010
• Aim to design integrated infection prevention
program focused on high-risk residents
TIP (TARGETED INFECTION PREVENTION PROGRAM):
STUDY DESIGN
Aims: To determine the effectiveness of a multimodal intervention in reducing:
1. MDRO prevalence
2. New, incident device-related infections
Design: Cluster-randomized trial
Facilities: 12 Nursing Homes in SE Michigan
Population: Residents with indwelling urinary
catheters and feeding tubes
HYPOTHESES
A multi-modal evidence-based Targeted Infection
Program (TIP) intervention will:
- reduce the burden of MDROs &
- incident device-related infections
in high risk NH residents with urinary catheters
and/or feeding tubes
TIP INTERVENTION DETAILS
Intervention Group (TIP)
Precautions Preemptive enhanced barrier precautions
Glove and gown use for AM, PM care
Control Group (Usual Care)
Standard precautions as per
NH policy
Surveillance Active surveillance
Cultures collected at baseline, D15, and then
MDROs
Passive surveillance
monthly and reported back to the facilities every
month, along with reminders of key strategies to
prevent infections
Infections Infections identified by study definitions and
reported back to the facilities q30d, along with
reminders of key strategies to prevent
infections
Education Hand hygiene promotion
Posters, videos, Glo GermTM, pre-post cultures
Interactive infection prevention modules
9 sessions for healthcare workers
Infection surveillance pocket cards
Provided to nurse, nurse aide, physician, and
infection preventionist upon resident enrollment
Half-day IP skills mini-conference
Clinical cultures, hospital discharge
reports, Cultures collected for
outcome evaluation with no
feedback
Infections identified by study
definitions for outcome
evaluation only, no reports
given to the facilities
Education provided as needed
(i.e., annual requirements, in
response to state surveys or
audits, etc.)
PRIMARY OUTCOME: REDUCE MDRO
BURDEN
nares
oropharynx
device
peri-anal area
groin
Outcome measures =
patient-level colonization, device-associated
infections
Staphyloccocus
Enterococcus
aureus
spp.
Gram negatives
wound
Methicillin
Vancomycin
Ceftazidime, Cipro
SECONDARY OUTCOME: REDUCE INFECTIONS
• Device associated infections:
– Indwelling CAUTIs
• uretheral catheters
• suprapubic catheters
– Skin and soft tissue infections around feeding tube
sites
• Clinical infection definition
– Specific infection documentation in chart followed
by at least three days of systemic antibiotics
STATISTICAL ANALYSES
• Primary outcome: MDRO Prevalence
– Mixed-effect multi-level Poisson regression model to
predict the mean number of MDROs/visit as a function of
intervention, including facility as a random effect and
offset by the number of cultures obtained at each visit.
– Excluded patients with only one visit
– Controlled for baseline colonization
– Log transformation with ratios based on geometric means
• Secondary outcome: Device-associated infections
– Cox proportional hazard model to predict time to first
infection while adjusting for patient-level and facility level
predictors
13 Nursing homes screened for eligibility
1 Nursing home did not participate
12 Nursing homes randomized
6 Nursing homes assigned to Intervention Cohort
6 Nursing homes assigned to Control Cohort
589 Nursing home residents assessed for eligibility
641 Nursing home residents assessed for eligibility
206 Nursing home residents not eligible:
58 Unable to reach family/guardian
74 Discharged before enrollment
41 Device was discontinued before
enrollment
18 Died before enrollment
15 Other
383 Nursing home residents eligible
180 Resident/family/guardian refused
203 (53%) Nursing home residents enrolled
49 residents with baseline visit only
41 Reached end point
3 Died
2 Withdrew
2 Other
154 Residents with more than 1 follow-up visit
119 Reached end point
24 Died
9 Residents withdrew
2 Other
245 Nursing home residents not eligible:
46 Unable to reach family/guardian
112 Discharged before enrollment
67 Device was discontinued before
enrollment
10 Died before enrollment
10 Other
396 Nursing home residents eligible
181 Resident/family/guardian refused
215 (54%) Nursing home residents enrolled
53 residents with baseline visit only
48 Reached end point
5 Died
0 Withdrew
0 Other
162 Residents with more than 1 follow-up visit
138 Reached end point
17 Died
4 Residents withdrew
3 Other
DESCRIPTION OF NURSING HOMES
Facility
Beds
Intervention
H
136
D
156
F
L
A
C
217
94
180
88
Mean
145·2
Control
B
J
120
91
G
K
E
I
149
135
180
99
Mean
129·0
Ownership
Status
Star
Mean Age, Mean CoRating y
Morbidity
Score
Mean
Male, %
Functiona
l Status
Gov.
Not for
profit
For profit
For profit
For profit
For profit
5
2
78·4
77·4
3·1
2·6
20·2
20·9
50·0
50·0
4
3
2
1
70·9
74·1
73·7
74·6
2·7
3·2
2·8
3·4
22·5
23·3
23·9
22·6
38·6
65·0
33·3
57·9
2·8
74·4
2·8
22·0
56·3
4
5
75·9
84·7
3·4
2·6
22·8
21·5
53·3
50·0
4
3
2
1
61·1
64·7
71·4
74·8
1·9
3·5
3·2
2·9
22·6
23·8
21·1
21·4
64·7
68·4
58·5
42·9
3·2
72·5
3·0
21·6
49·1
Gov.
Not for
profit
For profit
For profit
For profit
For profit
ENROLLED & VISITED
# Enrolled
418 residents with
Feeding tubes,
Urinary catheters
Intervention
203
Control
215
# Visits = 1830
Intervention
920
Control
910
Mean f/u:
4.5 visits
Mean f/u:
4.2 visits
ENHANCED BARRIER PRECAUTIONS
SIGNAGE
RESIDENT PRECAUTIONS
This resident is taking place in a Research Study
Resident
Room
BEFORE ENTERING RESIDENT ROOM
Please wash your hands and wear gloves
WHEN
PROVIDING DIRECT CARE
Please wear protective gowns
AFTER LEAVING RESIDENT ROOM
Please remove gloves and wash your hands
HAND HYGIENE POSTERS (ROTATING 4-5M)
HAND HYGIENE POSTERS 2
HIT THE ROAD GERMS!!
Nurse Clean Hands!
GERMS
!
A song and dance to practice
hand hygiene
BASELINE CHARACTERISTICS
Residents with more than 1 f/u visit
Characteristic
Follow-up Days, mean (SD)
Intervention Group Control Group
P-value
116·1 (121·1)
104·2 (123·5)
0·38
Age, mean (SD)
Males, n (%)
White, n (%)
Co-morbidity Score, mean (SD)
74·0 (12·4)
76 (49·4)
132 (85.7)
2·8 (1·6)
72·2 (13·5)
93 (57·4)
144 (88.9)
2·9 (2·1)
0·22
0·15
.39
0·66
PSMS, mean (SD)
Device Use, n (%)
Urinary Catheter
Feeding Tube
Both
22·6 (4·1)
22·1 (4·1)
0·23
84 (54·6)
46 (29·9)
24 (15·6)
79 (48·8)
54 (33·3)
29 (17·9)
0·30
0·50
0·58
21 (13·6)
9 (5·8)
32 (20·8)
29 (17·9)
13 (8·0)
39 (24·1)
0·29
0·44
0·48
Prior History of MDRO, n (%)
MRSA
VRE
R-GNB
ACTIVE SURVEILLANCE CULTURES, BY VISIT
Follow-up Visit, days
0 (baseline)
15
30
60
90
120
150
180
210
240
270
300
330
360
Total
No. swabs collected (%)
Intervention
Control
473 (48·5)
483 (50·5)
433 (49·7)
439 (50·3)
375 (52·6)
338 (47·4)
317 (54·0)
270 (46·0)
254 (57·0)
192 (43·1)
184 (54·6)
153 (45·4)
129 (48·5)
137 (51·5)
137 (52·9)
122 (47·1)
134 (52·0)
124 (48·1)
102 (45·5)
122 (54·5)
97 (47·6)
107 (52·5)
81 (43·3)
106 (56·7)
73 (48·3)
78 (51·7)
52 (59·1)
36 (40·9)
2841 (51·2)
2707 (48·8)
ACTIVE SURVEILLANCE CULTURES, BY SITE
Anatomic Site
Nares
Oropharynx
Groin
Perianal
Enteral feeding
tube site
Suprapubic
catheter site
Wounds
Total
Swabs Collected (%)
Intervention
Control
704 (51·1)
674 (48·9)
561 (52·0)
517 (48·0)
728 (51·7)
680 (48·3)
345 (52·1)
317 (47·9)
341 (51·0)
329 (49·1)
131 (45·5)
157 (54·5)
31 (48·4)
2841 (51·2)
33 (51·6)
2707 (48·8)
MICROBIAL SURVEY FOR MDROS
MRSA
Nares
Oropharnyx
Groin
Perianal
Feeding Tube Site
Suprapubic Catheter Site
Wound
VRE
Nares
Oropharnyx
Groin
Perianal
Feeding Tube site
Suprapubic Catheter site
Wound
Number of MDRO Positive Samples
No. Positive Samples/No. Samples Collected (%)
Intervention
Control
254/3116 (8·2)
323/3072 (10·5)
70/767 (9·1)
96/755 (12·7)
34/606 (5·6)
23/576 (4·0)
50/794 (6·3)
66/762 (8·7)
24/394 (6·1)
48/380 (12·6)
35/370 (9·5)
39/374 (10·4)
32/149 (21·5)
43/177 (24·3)
9/36 (25·0)
8/48 (16·7)
122/3116 (3·9)
162/3072 (5·3)
0/767 (0·00)
3/755 (0·4)
8/606 (1·3)
12/576 (2·1)
56/794 (7·1)
71/762 (9·3)
47/394 (11·9)
52/380 (13·7)
5/370 (1·4)
4/374 (1·1)
5/149 (3·4)
15/177 (8·5)
1/36 (2·8)
5/48 (10·4)
MICROBIAL SURVEY FOR MDROS (CONT’D)
CTZ-R GNB
Nares
Oropharnyx
Groin
Perianal
Feeding Tube Site
Suprapubic Catheter Site
Wound
CIP-R GNB
Nares
Oropharnyx
Groin
Perianal
Feeding Tube Site
Suprapubic Catheter Site
Wound
Number of MDRO Positive Samples
No. Positive Samples/No. Samples Collected (%)
Intervention
Control
168/3116 (5·4)
257/3072 (8·4)
1/767 (0·1)
18/755 (2·4)
10/606 (1·7)
27/576 (4·7)
61/794 (7·7)
72/762 (9·5)
52/394 (13·2)
74/380 (19·5)
9/370 (2·4)
15/374 (4·0)
26/149 (17·5)
25/177 (14·1)
9/36 (25·0)
26/48 (54·2)
609/3116 (19·5)
742/3072 (24·2)
12/767 (1·6)
31/755 (4·1)
36/606 (5·9)
57/576 (9·9)
240/794 (30·2)
294/762 (38·6)
207/394 (52·5)
207/380 (54·5)
34/370 (9·2)
65/149 (43·6)
15/36 (41·7)
42/374 (11·2)
75/177 (42·4)
36/48 (75·0)
CLUSTER-LEVEL SUMMARY OF ACTIVE
SURVEILLANCE CULTURES
Active surveillance cultures for MDROs
Facility
H
D
F
C
A
L
Intervention
E
I
B
G
J
K
Control
First month
Swabs
Positive
collected swabs, %
30
38
106
19
59
23
275
96
52
24
59
34
100
365
13·3
23·7
24·5
26·3
42·4
56·5
31·1
27·1
28·9
29·2
32·2
32·4
53·0
33·8
Study period
Swabs
Positive
collected swabs, %
272
436
1283
291
391
168
2841
821
300
354
380
421
428
2707
22·4
20·0
28·9
16·5
29·9
36·9
25·8
27·8
34·3
24·1
40·5
26·6
43·7
32·8
Difference
(Study period–First
month), %
9·1
-3·7
4·4
-9·8
-12·5
-19·6
-5·3
0·7
5·4
-5·1
8·3
-5·8
-9·3
-1·0
MDRO PREVALENCE RATES
Intervention
(N=154
residents)
Control
(N=162
residents)
Clusteradjusted
Rate Ratio
Cluster and covariate
adjusted
Rate Ratio,
Algebraic Mean
Cluster and
co-variate
adjusted
Rate Ratio,
Geometric
Mean
0·67
0·65
0·77
No.
%
No.
%
MDRO
Positive MDRO
Positive
isolated swabs
isolated swabs
All MDRO 1299
MRSA
VRE
254
122
26·6
8·2
3·9
1732
323
162
32·6
10·5
5·3
(0·51– 0·88)* (0·50–0·85)*
(0·62–0·94)*
0·92
0·81
0·78
(0·55–1·53)
(0·55–1·18)
(0·64–0·96)*
1·78
1·81
1·20
(0·68–4·67)
CTZ-R
CIP-R
185
738
5·4
19·5
295
952
8·4
24·2
(0·72–4·55)
(0·82–1·75)
0·93
0·87
0·94
(0·50–1·72)
(0·49–1·55)
(0·61–1·44)
0·94
0·96
0·75
(0·61–1·46)
(0·63–1·47)
(0·58–0·97)*
CLINICALLY-DEFINED INFECTIONS
Intervention
Group
Control Group
ClusterP-value Cluster &
Padjusted
Covariate-adjusted value
Hazard Ratio
Hazard Ratio
Infections Device Infections Device-Days
Days
First new CAUTI
31
5,982 43
All new CAUTIs,
56
includes recurrent
infections
9,413 75
Feeding tubeassociated skin &
soft tissue
infection
4
5,635 3
Feeding tubeassociated
pneumonia
10
4,292
0·49
0·022
0·54 (0·30–0·97)
0·039
8,118
(0·27–0·90)
0·62
0·008
0·69 (0·49–0·99)
0·045
0·72
1·09 (0·22–5·45)
0·92
0·88
1·83 (0·53–6·31)
0·34
(0·43–0·88)
5,062
1·21
(0·43–3·43)
5,635 8
5,062
1·09
(0·36–3·26)
EVALUATION OF IMPLEMENTATION PROCESS
• Use of appropriate surveillance definitions to
monitor infections
– Baseline: Intervention & Control: 3/6 used NH app. surveillance def.
– Study end: Intervention: 6/6; Control: 3/6 used surveillance def.
• HCW knowledge scores
– 300 in-services across 9 topics over 3 years
– attendance ranged from 211 to 375 HCWs (38·0%–68·2% of nursing staff
working that day)/topic.
– Post-test knowledge scores in the intervention group were significantly
higher than the control group for all education modules combined
[88·7% vs. 76·5%; mean difference 12·2 (11·3–13·1); P<0·001].
EVALUATION OF IMPLEMENTATION PROCESS
(CONT’D)
• 472 in-room observation periods (30 mins. each)
– 112 observations without any HCW entry
– 366 observations with 658 opp. to observe HCW
• Gown use: Higher in the intervention group than in the control
group (40·5% vs. 1·8%; mean difference 38·7 (20·3–57·1); P<0·001)
• In-room hand hygiene compliance: 37·3% vs. 18·2%; mean
difference 19·2 (1·4–36·9); P=0·03.
• No differences in participant self-reporting:
– Washed in the last 24 hrs. (79·8% vs. 81·9%; P=0·84)
– Overall satisfaction with care (83·3% vs. 83·9%; P=0·95)
SUMMARY/DISCUSSION
• Our multi-modal TIP intervention significantly
reduced MDRO prevalence density and
clinically-defined CAUTI rates in NH residents
with indwelling devices
– Reduced overall MDRO prevalence in high risk
residents by 23%
– Reduced clinically-defined CAUTIs by 31%
DISCUSSION/LIMITATIONS
• Few clusters, focused in one geographic area
• Targeted one high risk group of residents- with
indwelling devices
• Did not evaluate the impact of our intervention
on transmission to room-mates, environment,
referring hospitals
• Using the horizontal approach, our power
calculations were based on overall prevalence of
MDROs and not individual organisms
• Use of clinically-defined infections
DISCUSSION/STRENGTHS
• Intervention components designed with the aim
to integrate individual practices into routine
clinical settings
– We showed the beneficial effects of a predominantly
organizational, healthcare-worker based
intervention
– Simplified intervention designed for high-risk
patients rather than individual MDROs
• Engaged a group of NHs in rigorous infection
prevention interventions that involved facility
IPs, leadership, clinical and non-clinical staff
BRINGING ABOUT A CHANGE:
THE CHANAKYA WAY (370-283 BCE)
• ‘Sham’: reasoning, negotiations,
‘evidence-based’
• ‘Dam’: reward, ‘carrot’,
‘incentives’
• ‘Dand’: ‘stick’, discipline
‘F tags’ or ‘citations’
• ‘Bhed’: differentiating good from bad
‘star ratings’
HAND HYGIENE CONTEST!
• To promote hand hygiene compliance we created a contest for
the 6 intervention sites to boost rates of carrying a personal
bottle of hand sanitizer
• Collected 1 baseline audit and 4 follow-up audits over 4
weeks
• Asked employees with direct patient care at each site if they
had their hand sanitizer on them (on a clip or in pocket)
• Calculated results:
# Had hand sanitizer x 100 = % Compliance
# Asked
Mean Overall Increase from Baseline: 21%
ATTRIBUTES OF A WELL RUN INFECTION
PREVENTION PROGRAM
Culture supportive of Infection Prevention
• Infection preventionist enthusiasm,
commitment, training, time spent
• Director of nursing attendance at the inservices
• ICP and DON relationship
High hand hygiene rates to begin with
High attendance at each in-service
• often 3-5 sessions so that all staff may attend
HAI PREVENTION ACTION PLAN: PHASE 3
• National action plan to prevent healthcare-associated
infections: roadmap to elimination
– Phase 3: Long-term care facilities
– Priority areas:
• Facilitate standardized infection reporting
• Reduce catheter-associated UTIs
• Enhance influenza vaccine uptake among short stay
residents and healthcare workers
• Standardize C. difficile surveillance processes
MRS. DECKER
• Two indwelling devices, functional disability & wounds
– High risk for infections and new MDRO acquisition
– Presence of wounds increase the risk of cocolonization with MRSA and VRE
– She can have up to 3 new infections/yr.
• She can continue PT, OT and Speech therapy
– Potential for social isolation
• Anticipate reassessment of her rehab potential and
future goals of care
SUMMARY
• Risk factors for MDROs:
– Recent hospitalization
– Functional disability
– Indwelling devices
– Presence of wounds
• Strategies:
– Identify high risk groups, common infections, MDROs
– QA programs to implement strategies to reduce MDROs,
infections
– Hand hygiene, enhanced barrier precautions, environmental
cleaning, antimicrobial stewardship, staff education
ACKNOWLEDGEMENTS
All participating facilities, HCWs,
residents
Co-Investigators:
Suzanne Bradley, MD (ID, Geriatrics)
Andrzej Galecki, MD, Ph.d (IoG)
Mohammed Kabeto, MS (IoG)
Carol Kauffman, MD (ID)
Sarah Krein, Ph.d (Gen Med, HSR)
Lillian Min, MD, MPH (Geriatrics)
Sanjay Saint, MD, M.P.H (Gen Med, HSR)
Ana Montoya, MD (Geriatrics)
Consultants:
Tom Fitzgerald, Ph. D (GRECC AD, Ed)
Russ Olmsted, (Hosp. Epidemiologist)
Ruth-Anne Rye, (Infection Preventionist)
Field Team:
Bonnie Lansing, LPN
Sara McNamara, MPH
Dianna Hammer, RN
Lab team:
Kathy Symons
Kay Cherian
Evonne Koo
Trainees, Mentees and Students:
Kristen Gibson (SPH)
Amanda Horcher (SPH)
Jay Fisch, MS
Linda Wang, BS
VA Healthcare System Geriatric Research Clinical Care Center (GRECC, Mody), NIA-Pepper Center (Mody), NIH
(K23AG028943 and R01AG032298 Mody), T Franklin Williams (Mody), AHRQ (R18HS019979 Mody), a hand sanitizer
company for donating personal use bottles – approved by NIA.