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