2017 NHSN Training – Infection Surveillance and Prevention in LTC: A National Perspective

>>Good morning, everyone. Good morning. It’s 9:30, and so we want
to go ahead and get started. I know many of you have been
here for some time now. And hopefully you had breakfast
and your caffeine in you and you’re ready to get started with us. So happy Monday, and welcome to NHSN
2017 training long term care session. We have a packed agenda today. But before I get started, I’ve been
asked to share a few things with you. For this conference area, they have some safety
briefings that we have to share with you. In the event that there is an emergency and
we all need to evacuate, we just ask everyone, you know, follow the exit signs
and assemble on Michael Street, that’s actually behind this building. But I’m sure if we’re all going out
together, we’ll go in the same direction. And at that point, we’ll receive directions
as to whether or not we would come back in or we’d have to leave the campus or whatnot. And I just have a few housekeeping things. There are continuing education
credits available to everyone. There’s information about that and
how to obtain that in your folder. For those who are watching online, there
should be an e-mail that will be sent to you with further instructions. We’re taking attendance. And Avaris is actually the conference contractor
who’s helping us set everything up today. You’ve been interacting with them probably this
morning already and we just want to make sure that you’re reminded to check
in with them every day. There’s also an opportunity for
you to interact with your speakers. So you notice on your table
there’s a little orange bucket. It has polling devices available to you. Hopefully there’s one for everyone at your
table, but if not, you know, be a kind neighbor and share with the person with you. But make sure that you return
it at the end of the session. We don’t want any missing devices. And also, as you notice, we
welcome food and snacks in here. We want everyone to be comfortable. We have some treats for you at the table. I noticed that many of you have found
the cafeteria already, so that’s good. You probably saw the vending machine there. I believe there’s another vending
machine down the hall and to my right if you need to get something else. And for lunch options, some of you have
already opted in to buy a boxed lunch. But if you did not do that, the
cafeteria’s also available to you. We ask that no one take any pictures and
please silence your phones for, you know, the courtesy of your neighbor
and for the presenters. And finally, we ask everyone hold their
questions to the end of the presentations. We’ll have a time for people to go
to the mic and ask their questions. And many of you may have some burning
questions about particular cases or experiences that you’ve had in your workplace. And we just ask that if you have
anything specific to a particular patient or a particular case and it’s
very detailed that you reserve that question and send it to NHSN at cdc.gov. We also have to disclose the fact
that we have no financial conflicts, no commercial support had been given
for the continuing education activities. And all the examples that you
will see today are fictitious. We don’t use actual data from NHSN
in any of the presentations today. And so now that I got that all
out the way, welcome again. We’re so excited to have you all here. I have to say the long term care team,
we’ve been anticipating this moment for quite some time and we look forward to
the opportunity to interact with you all. I have the pleasure of being
your first speaker today. My name is Janeita Bell. I’m the long term care team lead for NHSN. And today I will talk to you about
infection surveillance and prevention in long term care from a national perspective. Usually when I do talks on surveillance, I like to start with the definition
of public health surveillance. I found in just my everyday life when people
hear surveillance, they typically think of the NSA or Big Brother watching you
from many monitors in a room [laughs]. My family thinks so anyway. But CDC has defined public health surveillance
as the, “Ongoing, systematic collection, analysis, and interpretation and dissemination
of data regarding a health-related event” — so it can be a disease, a
condition, or injury — “to reduce morbidity and
mortality and to improve health.” Public health surveillance
has many characteristics. And primarily, it’s used to provide
data to facilitate prevention and control of a health condition. Its objectives determine how the
data is collected and analyzed. It has many attributes, and
I listed some of them here. The first one I have here is
susceptibility; that reflects the willingness of people or organizations to participate. There’s also sensitivity, which refers
to the proportion of cases of a disease that the surveillance system captures. Positive predictive value is the
proportion of cases that actually represent or have a health-related event of interest. Timeliness often refers to the time
interval between when a case actually occurs and when it’s reported into
our surveillance system. Stability refers to the reliability of the
system and availability of it when you need it. And representativeness is the degree to
which it accurately describes the occurrence of a health-related event
over time and its distribution in a population by person and place. And so instead of trying to continue to
describe this to you in an abstract way, I have a few real-life examples I
think you may be able to relate to. The first one is my absolute favorite. I think it’s been my favorite
since I’ve been here at CDC. When I first saw it, it was
just really compelling to me. This is a map of the U.S.,
and it depicts the prevalence of self-reported obesity among
U.S. adults by state and territory. The BRFSS is the Behavioral
Risk Factor Surveillance System. Some of you may have experience with it. But it’s one of the largest
systems that CDC has. It’s implemented on an ongoing basis, and the data is required by
conducting random interviews. So some of you may have been contacted. They conduct phone calls to landlines and cell
phones and collect information from people. And apparently they collect enough information
to be able to calculate a body mass index and determine whether or not you’re obese,
and so the data here represents that. But before I move on, I want to make sure
I orient you to the map a little bit more. If you look at the lower, right-hand corner, you notice that the green color
represents the lower prevalences with the highest being orange and red. Red is greater than or equal to 35%. So I have a few slides with this same map. I want you to pay attention to the
color and where it is on the U.S. So first we have 2011, and
2012, 2013, 2014 and 2015. So I think this map is a beautiful depiction
of how surveillance can benefit you. It highlights benefits and the
trend data that’s available. And in a matter of seconds I was able
to convey to you the burden of obesity in the United States, how
that has changed over time, and what regions are the most adversely
affected and the least adversely affected. So that’s surveillance, one thing
surveillance can do for you. You could also conduct surveillance
over a smaller time frame. The example that I have here is what we
often call in public health an epi curve. We do this when outbreaks occur. But it’s basically essentially a bar graph. And this bar graph shows diarrheal illness in
city residents by date of onset and character of stool from December 1989 to January 1990. On the horizontal axis, you have time, and on
the vertical axis, you have the number of cases. And the different shades of the bar graph
represents the character of the stool. You’ll also notice that there’s some
historical data mapped onto the bar graph. And let’s look a bit closer at the graph
so you can see what this is depicting. Around December 16th, they noticed
their first case of diarrhea. The cases began to increase over time. And you notice when the water main breaks, the increase continued and
peaked around January 1st. Then the boil water order was issued. They saw a small decline in cases as it
wasn’t until chlorination occurred of water that cases gradually declined
and then no longer were detected. So not only were the investigators able
to characterize the trend of this illness over a small period of time, but they’re
also able to look at historic data to determine what a potential cause of prevention may have been
for this particular outbreak. Do we need this for long term care? I have no doubt in my mind that
all of you would agree with me and answer that question by saying yes. At some level, surveillance probably
already occurs in long term care facilities, particularly similar to the
example that I just gave. In the event that there’s an
outbreak, you want to track cases and understand what the cause
and prevention was. But let’s talk about this on a national scale. I want to proceed with my presentation by
telling you why I believe this is needed in long term care and how
NHSN can help meet that need. So we know from epidemiological studies of
long term care facilities that there are over 4 million people who are
admitted to or reside in nursing homes and skilled nursing facilities each year. Infections are the most frequent cause
of transfers and hospital readmissions, and an estimated 380,000 deaths occur
every year as a result of infections. Approximately 2.8 million
infections occur in nursing homes and skilled nursing facilities every year with the most frequent being urinary tract
infections, lower respiratory tract infections, skin and soft tissue infections,
and gastroenteritis. In support of this evidence,
you’ll see this table here. In 2011, the Office of the Inspector General
conducted a study among skilled nursing facilities and looked at adverse events. 653 facilities were observed and
a report was released in 2014. The adverse events were categorized
into three categories: events related to medication,
resident care, and infections. Infections represented 26%, and that’s
what’s represented in the table here. With the most frequent being aspiration,
pneumonia and other infections, SSIs, catheter-associated UTI, and
clostridium difficile infection. So although — you’ll notice in this table
— although CDI represents a small proportion of the infections, it still is a significant
event because of the associated morbidity and mortality with clostridium difficile. Not only that, it’s a public health threat. CDC even included it in its
antibiotic-resistance threat report of 2013. At least 250,000 CDIs occur per year. 50% of CDI occur in people younger than 65. However, more than 90% of deaths occur in people
65 and older, with 50% first showing signs and symptoms while they’re
in a nursing home or shortly after visiting a doctor’s office or clinic. Colleagues here at CDC conducted a more in-depth
analysis of nursing home onset CDI in order to determine what the burden
is in the United States. They conducted surveillance
sampling of ten geographic areas and derived a 2012 national estimate. They found that in 2012, approximately
112,000 CDI cases were nursing home onset. And upon a medical review of a sample of those
cases, those who were infected had a median age of 82 years, and 76% had received antibiotics. Now so the data that I’ve presented
to you so far may seem sufficient, but there are some limitations that we need to
overcome to better inform prevention efforts. For example, the data that I
presented to you — some of it — was derived from hospital surveillance. And that may not accurately
capture nursing home admissions. National estimates that I’ve presented
in the previous slide were extrapolated from few geographic areas and therefore
the representativeness can be questioned. Incidents estimates from that study as well
are not based on nursing home populations because of the lack of denominator data of
the overall nursing home resident population. And so all these things collectively
cause us to underestimate the true burden of health care associated infections, or HAIs
in nursing homes across the U.S. And also, they lack the details necessary
to conduct national state or facility level prevention on some levels. So how can surveillance help? Well, the definition I gave to you earlier that surveillance is the ongoing systematic
collection, analysis and interpretation of data; and that alone allows you to
characterize the national burden of HAI, establish a national baseline for the
incidents of HAI, identify associated risks and protective factors, evaluate
intervention effectiveness and monitor incidents trends
and identify outbreaks. NSHN was created for this purpose in
recognition of these many data gaps. Although NHSN was launched in 2005, the long term care component did not
become available until September of 2012. It has modules for the reporting of
UTIs, multidrug-resistant organisms, and adherence to hand hygiene
and gown and glove use in CDI. All of these will be discussed in
detail by the presenters that follow me. They will describe to you how standardized
definitions help with the systematic collection of data and how those data can then be
analyzed to help you understand epidemiology of any health event within the
facility and between facilities. So here, I have a few maps just to show
you how participation in NHSN has grown. Approximately a year after its launch,
we had 130 nursing homes participating. June of 2016, we had 307. And as of March this year, we
have more than 2,000 nursing homes in NHSN representing all 50
states, D.C., and Puerto Rico. And this is important. The growth and participation will
set up the framework and allow us to take public health action and
will inform prevention efforts. So up to this point, I’ve focused mainly on, you
know, the national perspective and the benefits that it can have for us to help fill data gaps. But I want to make sure that I
acknowledge the benefits that it can have, particularly for long term care
facilities at a facility level. So there’s other needs. And I recognize — especially in nursing
homes — you all have many masters to serve, and it’s important that if
you adopt something like NHSN that it helps you kill more
than one bird with one stone. So here I have a few examples
listed that I could think of. There’s the Quality Assurance and
Performance Improvement requirement, or QAPI; Infection Prevention and Control Program;
Antibiotics Stewardship Program requirements; and local interventions you may want
to do within your facility itself. So let’s start with Quality Assurance
and Performance Improvement, QAPI. As many of you already know, there’s a section
of the Affordable Care Act that requires the CMS to establish regulations and quality
assurance and performance improvement and provide technical assistance
to nursing homes to help them develop best practices
to comply with the regulations. CMS has identified five strategic
areas that I have listed here that are considered the basic
building blocks of an effective QAPI. I mapped them here, and I
place NHSN at the center because I believe it’s related
to all these elements. When you decide to participate in NHSN,
it has to be part of a greater plan, and you have to have buy-in
from your leadership. But for an example, element three
is probably the most obvious link. It states that there should be
feedback, data systems and monitoring, and it states that the use of performance
indicators should be implemented to monitor care processes and outcomes, review
findings against performance benchmarks, track and investigate, monitor adverse
events, and prevention implementation. All these can be done within NHSN. Infection Prevention and
Control Program, or IPCP. You all also know that CMS reform
requirements for long term care stated that facilities should develop an IPCP program
and include at minimum a system for preventing, identifying, reporting, investigating, and controlling infections
and communicable diseases. It requires facilities to have written
standards, policies, procedures for a system of surveillance designed to identify
possible communicable diseases or infections, and there should be reporting
requirements in place for possible incidents of communicable diseases or infections. So in this case, long term care
facilities don’t have to start from scratch and reinvent the wheel. All these things are available to them through
NHSN in order to fulfill these specifications. For antibiotic stewardship programs,
there’s also reform requirements listed in the rule there that was released by CMS
last year, and it states that in addition to the IPCP program, there should
be an Antibiotic Stewardship Program and facilities should designate at
least one infection preventionist. The program should include
antibiotic use protocols and a system to monitor antibiotic use. Now NHSN does not have an antibiotic
stewardship or antibiotic use module yet — we’re working on that — but there’s
other features that a facility could use. For example, CDC’s core elements of
antibiotic stewardship is actually represented on the annual surveys that
facilities participating in NHSN has to complete every year. The UTI module allows for
one to report antibiotic use, and then there’s the LabID module that
will allow you to report on organisms that are related to antibiotic stewardship. So all these elements can be used to help
facilities determine what their framework is, its effectiveness and performance
regarding antibiotic stewardship. So up unto this point, I’ve been
idealistic in my presentation. And I want to take a moment and acknowledge
that there are some challenges with NHSN. Everything has its pros and
cons, and NHSN is no exception. I have to say that the long term care
team has taken a systematic approach. We know that there are some barriers
and challenges that are inherent to the system itself, but we’re grateful for the
opportunity to receive feedback from you all. Because you all are using the system in
a way that we can never use the system. And so we want to make sure that the function
of NHSN is conducive to your working environment and how you have to deal with
things on a regular basis. We take note of all those
things that come in to us. We’ve listed some things ourselves, which
is represented in the table, some of them. And we try as immediately as we can to
develop short-term solutions to resolve issues that users bring to our attention
or we come across ourselves. But I have to say that the feedback’s
also important because it equips us with the information that we need to
petition our leadership for long term change. So some things need to happen from an
infrastructure standpoint and won’t happen as immediately, but we can
at least get the ball rolling so that you’ll have a better
NSHN experience in the future, and we can continue to advocate on your behalf. Now [laughs] I hear laughter in the room. Some of you all had the unfortunate
experience of NHSN 8.6 defects. With the release of NHSN 8.6 in January this
year, we had widespread technical difficulties. It affected all components, all stages of user
participation from enrollment to analysis, and it even affected our internal data systems. I have to say that I thought this picture
was fitting because there were days when the team came to work as we
were all like this at our desks. Because it’s frustrating to know that
we are inhibited in our own work, but to know that you are inhibited in your work. We want to make sure that this
thing runs smoothly on your behalf. And I have to say that, you know, the IT teams
are constantly on task, and they resolved many of the issues that came along with 8.6 and
some of them are still, you know, to come. And then — yeah, it was just
an unprecedented experience. And some of you who are already
users of NHSN you know also that the application was taken offline last week because some security vulnerabilities
were detected. And I have to say, though,
that no data breach occurred. I want to assure you that. And they’re working on that. We’re expecting an announcement today and
update as to where we stand with that. But, you know, it was unscheduled
maintenance, but it’s done for the protection of the information that’s in there. We have to secure the data and protect people’s,
you know, information, their health data. But with all that being said, I
still think there is hope [laughs]. You know, whatever defects that have occurred
and probably will occur in the future, and other technical difficulties,
the long term care team and the folks over at NHSN are really dedicated to making
sure that we accomplish our mission at hand. I mean, we’re all in public health
because we have a heart for people, we have a heart of service, and so we were all
disturbed by the things that you experienced that inconvenienced you and
challenged you in your workplaces. But we have to keep the ball moving
and moving forward with our mission to protect public health in long term care
communities, and we’re very dedicated to that. And so the defects will be repaired,
the technical issues will be resolved. And we appreciate your patience and
the patience you’ve given us thus far to help resolve those things. Now that I’ve acknowledged the elephant in the
room, I hope that [laughs] — I just had to — I just hope that, you know, moving forward
with today’s sessions that we’ll be able to at least focus on the content here. Because this is an opportunity we don’t
get often to interact with you all. And you have the subject matter
experts at your disposal. I just want to make sure that we use
that to our benefit as much as possible. I am almost done with my remarks, but I have a
short announcement I want you all to consider. We have other colleagues within our division
who works on long term care topics — it’s just not restricted to NHSN — and
they have a project that they’re going to launch very soon — it’s the assessment
of infections and use of antibiotics in nursing homes and skilled
nursing facilities . In the spring of this year
— which is very soon — they hope to have about 200
facilities participate. And they will help collect data from
resident charts and other records about HAIs, antibiotics administered and how they’re
used within long term care facilities. The information will then be
used to develop interventions and help inform surveillance efforts
like that of NHSN and identify how to best support antibiotic stewardship. Here, I have a table that lists all the
states that we’re expecting to participate and the counties in those states. All CMS certified nursing homes
and skilled nursing facilities in these areas are eligible to participate. So we hope that if someone reaches out to
you and you’re contacted that you will elect to become a part of this important study. So thank you all for your attention, and
I will release you to the next speaker. [ Applause ]

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