Long-Term and Acute-Care Organizations Collaborate to Fight Infection

By Susan Carr

PSQH, like most of the safety and quality improvement community, has focused primarily on hospitals and increasingly on primary care. At the annual conference of the Association of Professionals in Infection Control (APIC) earlier this month, I learned about important improvement work underway in long-term care (LTC) facilities. Current trends, such as the growth of accountable care and baby boomers easing into old age, will bring increasing attention to the quality and efficiency of LTC. Based on what I heard at APIC, there’s valuable work being done, success stories to share, and tremendous—if elementary—challenges ahead.

At APIC, I attended a three-part session that reported on efforts to decrease rates of healthcare-associated infections (HAIs) in nursing homes and skilled nursing facilities. Nimalie Stone, MD, MS, medical epidemiologist for LTC in the Division of Healthcare Quality Promotion at the Center for Disease Control and Prevention (CDC), described recent updates to a national collaborative called Advancing Excellence in America’s Nursing Homes. More than 9,000 nursing homes in the United States participate in the collaborative, which is led by a board comprised of representatives from 31 public and private organizations (described in more detail in a recent press release). 

Stone highlighted three new goals the collaborative identified in 2012: 

• Reducing hospitalizations (or readmissions, from the hospital’s perspective). Stone pointed out that hospitals will know over time which nursing homes are more likely to bounce patients back to the hospital for those notorious 30-day readmissions that are no longer reimbursed. Hospitals have skin in this game now, too—a recurring theme of the session.
• Safe prevention and management of infections.
• Optimizing and improving appropriate use of medications. Anti-psychotic drugs are the focus of the first major initiative, but Stone said she “could easily see antibiotics substituted [for anti-psychotics] in the future.”

Stone observed that these efforts “speak to the changing awareness of nursing homes and skilled nursing in the healthcare continuum, in particular the partnership that needs to happen around promoting safe healthcare in the community.

Stone’s co-presenters described local improvement efforts in Kentucky and Vermont.

Andrea Flinchum, MPH, BSN, CIC, is HAI prevention program manager for Kentucky’s Dept. for Public Health.  She described a statewide project designed to reduce Clostridium difficile (C. diff.) and urinary tract infections (UTI) in nursing homes. The lessons learned from that 2-year effort reflect basic dynamics familiar to anyone involved in improvement work and serve as a reminder that many arenas are starting at square one.

The challenges Flinchum described include:

• Time and resources are extremely limited in LTC. Initially, none of the facilities had a full-time infection preventionist (IP) to devote to the project. Often, IPs did not have their own office spaces, computers, or even telephones, so they were continually borrowing resources from nursing, which made many of their tasks, and even simple communications, difficult.
• A large proportion of staff members in participating nursing homes lacked basic computer skills. Since statewide data collection was fundamental to the project, this was a barrier that had to be addressed. Additionally, developing a web interface for data reporting was a first-time effort for Kentucky, and the definitions used for reporting were also new, having transitioned from the long-used McGeer definitions to definitions established by the CDC for the National Healthcare Safety Network (NHSN) tracking system. Flinchum observed, “So we had long-term care folks, some of whom had little or no computer training and experience, trying to log onto a state site that didn’t work part of the time, using definitions they weren’t familiar with.
• Even basic infection control and clinical practices in many facilities were of poor quality. Urine specimens that should have been sterile often were not, requiring retraining of long-time staff members. Physicians and staff members had developed workarounds that too often resulted in inappropriate antibiotic prescriptions. Out of 1,142 cases of UTI reported by 24 facilities between April and November 2012, 823 cases had an MD diagnosis but did not meet requirements for NHSN definition of UTI.

Despite these and other challenges, Flinchum sees signs of progress that indicate real improvement, including increased FTE support for infection control at some facilities, new enrollments in NHSN, involvement with local APIC chapters, improvement in results from OIG inspections, and strong participation of collaborative members in a statewide conference and listserve.

Sally Hess, MPH, CIC, infection prevention manager at Fletcher Allen Health Care in Burlington, Vermont, reported on a statewide collaborative to engage nursing homes in preventing C. diff. and multi-drug resistant organism (MDRO) infections.

Having long-term and acute care facilities work together was a prime objective of this collaborative, which was organized into local clusters across the state. The cluster that included Hess’s acute-care hospital also involved one behavioral health hospital, five long-term care facilities, and participation from the Vermont Dept. of Health. Many of the collaborative activities Hess described involved close coordination among the participants, which included sharing knowledge and resources, especially from the hospital’s infection preventionist to the LTC facilities, and improved communication processes for transfer of patients from long-term to acute care and back again (and, hopefully, not back yet again).

Overall, the collaborative resulted in lower rates of infection. For example, the rate of C. diff. infections diagnosed in LTC patients within 28 days of discharge from Fletcher Allen (the acute care hospital) fell from more than 30 cases in FY 2010 to fewer than 30 cases in FY 2011 to just greater than 10 cases in FY 2012 and no cases in the first 6 months of FY 2013. 

Hess also reported other positive outcomes:

• Enhanced standard precautions and isolation protocols
• Recognizing needs related to the environment
• Improved communication between facilities 

From the perspective of the long-term care facilities, the collaborative also resulted in:

• Increased awareness of best practices
• NHSN enrollment & training
• Increased job satisfaction

Hess concluded her talk with a slide that emphasized the goal of cooperation and support across all healthcare settings:

The only way to have a new idea catch fire is to set it free in the world in ways that enable as many people as possible to begin using it constructively: Partner with your local Infection Prevention Teams.

In upcoming issues of PSQH (in print and online), we’ll be adding more stories about improvement efforts in long-term care and care coordination across different healthcare settings. Please let me know (susancarr@psqh.com) if you have suggestions or a story to share.