externalization of infection prevention and quality...

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

• Owner, LightClean Environmental Decontamination, LLC

• Speaker or Advisor (but none within past 2 years)

• Pfizer Pharmaceuticals

• Cubist Pharmaceuticals

• Research: Forest Labs, Cubist Pharmaceuticals (none

within the past 18 months)

Objectives—Why?

• Why does the government want to improve the

quality of healthcare in the US?

• Why has there been movement in CMS to cost-

sharing and Population Health?

• Why are Acute Hospitals interested in other

people’s business?

• Why were ACOs created?

Outline • Rise of government intervention

• ACA, ACO, CMS, NQF, AHRQ, CMS, NHSN

• White House National Strategy for Combating Antibiotic-

Resistant Bacteria

• Strategy to align care, coordination

• Cost sharing—CMS Models

• CMS 60 and 90 day cap program

• Continuum of care

• Local Responses

• LTC Collaborative

• Sepsis collaborative

• Infection Prevention in LTC

• CHF, Hips, Knees and money

• 30 Day Readmit Programs

SCOPE OF THE PROBLEM

GOVERNMENT RESPONSE

https://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf

Key Priorities:

• CRE

• MRSA

• Ceftriaxone Resistant

N gonorrhoeae

• C difficile

Players: NSC (National

Security Council), Office of

Science and Technology

Policy, HHS, USDA, DOD,

VA, EPA, USAID




National Strategy for Combating Antibiotic-Resistant

Bacteria

1. Slow the emergence of resistant bacteria

and prevent the spread of resistant

infections

a. --Healthcare—control across the spectrum

b. --Agriculture

i. Limit antibiotics in animal feed

ii. Prevent use without a vet prescription


Bacteria

2. Strengthen national “One-Health”

surveillance efforts to combat resistance a. Detection and Control

b. Integration of public health, veterinary, food and

environmental surveillance

c. Whole genome sequencing


Bacteria

3. Advance development and use of rapid

and innovative diagnostic tests for

identification and characterization of

resistant bacteria a. Point of need testing

b. Drive implementation to point of care


Bacteria

4. Accelerate basic and applied research

and development for new antibiotics, other

therapeutics and vaccines. a. Antibiotics

b. Vaccines

c. Other therapeutics and diagnostics


Bacteria

5. Improve international collaboration and

capacities for antibiotic resistance

prevention, surveillance, control, and

antibiotic research and development

2020 Goals (Money Slide!)

• Reduce incidence of C diff by 50%

compared to 2011

• Reduce CRE by 60% compared to 2011

• Maintain CTX-resistant NG to <2%

• Reduce MDRO Pseudomonas by 35%

• Reduce MRSA by 50%

• Reduce MDR-TB by 15%

SO, HOW DO WE DO THAT?

CMS Innovation Models

http://innovation.cms.gov/initi

atives/index.html#views=mo

dels

Hovering over the item

will tell you the:

Stage

# Participants

Category

Authority

links

CMS Innovation Models • 59 programs in 6 areas – Announced, under development, ongoing,

or no longer active

• Accountable Care Organizations (shared savings programs)-11 programs

9 active

• Bundled Payments for Care Improvement (10- 5 active)

• Model 2

• Model 3

• Model 4

• Primary Care Transformation (9- 6 active)

• Initiatives focused on the Medicaid and CHIP population (8- 6 active)

• Initiatives to Accelerate the Development and Testing of New Payment

and Service Delivery Models (13- 4 active)

• Initiatives to Speed the Adoption of Best Practices (7- 4 active)

http://innovation.cms.gov/initiatives/index.html#views=models



CMS Innovation Programs of Interest

• Comprehensive ESRD Care Initiative

• Next Generation ACO Model

• Nursing Home Value-based Purchasing Demonstration

• BPCI (Bundled Payments for Care Improvement) 30, 60, 90 days

cap

• Model 2: Retrospective Acute & Post Acute Care Episodes • Money to the hospital, covers all acute services PLUS post-acute stay

• Model 3: Retrospective Post Acute Care Episodes Only • Money goes to the LTC facility and covers only the post-acute stay

• Model 4: Retrospective Acute Care Episodes Only • Money to the Acute hospital and the bundle pays everyone

• Medicare Coordinated Care Demonstration (no longer active)

• Community-based Care Transitions Program

• Partnership for Patients

Innovation.cms.gov/initiatives/bundled-payments/index.html

CMS Innovations Model 3

Features CMS Innovation Models

• 48 different clinical conditions

• Triggered by acute hospital stay with

initiation of the bundle with the start of the

LTC stay

• Bundle for all services for 30, 60, or 90

days

48 Conditions covered under

Innovation Models • Acute myocardial infarction

• Amputation

• Atherosclerosis

• Automatic implantable cardiac defibrillator generator or

lead

• Back and neck except spinal fusion

• Cardiac arrhythmia

• Cardiac defibrillator

• Cardiac valve

• Cellulitis

• Cervical spinal fusion

• Chest pain

• Chronic obstructive pulmonary disease, bronchitis/asthma

• Combined anterior posterior spinal fusion

• Complex non-Cervical spinal fusion

• Congestive heart failure

• Coronary artery bypass graft surgery

• Diabetes

• Esophagitis, gastroenteritis and other digestive disorders

• Double joint replacement of the lower extremity

• Fractures femur and hip/pelvis

• Gastrointestinal hemorrhage

• Gastrointestinal obstruction

• Hip and femur procedures except major joint

• Lower extremity and humerus procedure except hip, foot,

femur

• Major bowel

• Major cardiovascular procedure

• Major joint replacement of the lower extremity

• Major joint replacement of upper extremity

• Medical non-infectious orthopedic

• Medical peripheral vascular disorders

• Nutritional and metabolic disorders

• Other knee procedures

• Other respiratory

• Other vascular surgery

• Pacemaker

• Pacemaker Device replacement or revision

• Percutaneous coronary intervention

• Red blood cell disorders

• Removal of orthopedic devices

• Renal failure

• Revision of the hip or knee

• Sepsis

• Simple pneumonia and respiratory infections

• Spinal fusion (non-Cervical)

• Stroke

• Syncope and collapse

• Transient ischemia

• Urinary tract infection

Expected Changes in Mandatory Reporting

• Crystal Ball Time!

• Mandatory Flu vaccine for all HCW

• Mandatory reporting of CRE, pan-

resistant Pseudomonas, and MDRO-

Acinetobacter

• Sepsis Bundle 3 hr.

• Sepsis Bundle 6 hr.

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-

Fact-sheets-items/2014-08-04.html

Expected Changes in Mandatory Reporting • NHSN

• 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-

Resistant Bugs

https://www.whitehouse.gov/sites/default/files/docs/carb_

national_strategy.pdf

• 2. http://innovation.cms.gov/initiatives/Advance-

Payment-ACO-Model/

• 3. Parkview Health—Internal Data

• 4. https://www.federalregister.gov/articles

/2015/02/27/2015-03751/patient-protection-and-

affordable-care-act-hhs-notice-of-benefit-and-payment-

parameters-for-2016



http://innovation.cms.gov/initiatives/Advance-Payment-ACO-Model/







Bibliography

• 5. http://innovation.cms.gov/initiatives/BPCI-Model-2/

• 6. http://innovation.cms.gov/initiatives/BPCI-Model-3/

• 7. Fiscal Year 2015 Policy and Payment Changes for Inpatient

Stays in Acute-Care Hospitals and Long-Term Care Hospitals --

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-

sheets/2014-Fact-sheets-items/2014-08-04.html

• 8. Special Section: Aging and Infectious Diseases: Robert A. Bonomo

Multiple Antibiotic-resistant Bacteria in Long-term-care Facilities: An

Emerging Problem in the Practice of Infectious Diseases Clin Infect Dis.

(2000) 31 (6): 1414-1422

• 9. http://www.health.gov/hai/prevent_hai.asp#hai_plan.

• 10. Indiana State Department of Health

http://innovation.cms.gov/initiatives/BPCI-Model-2/










http://www.health.gov/hai/prevent_hai.asp#hai_plan

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