infection compliance solutions for f880 and f881 – meeting
TRANSCRIPT
4/8/2021
Infection Compliance Solutions for F880 and F881 – Meeting the Requirements
Presented by:
Deb Martin RN, BSN, IP
Susan Ayers RN, BSN, LNHA, IP
Sponsored by: University of Indianapolis
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Reboot Your Infection Control Plan
• Susan Ayers, RN, BSN, LNHA, IP – Sue has been involved in long-term care for the past 30 years and is currently the IP for two SNFs in Iowa. Sue has experience as a DON, administrator, nurse consultant, and educator at the collegiate level. She has completed the IP course from APIC and from the CDC.
• Deb Martin, RN, BSN, IP – Deb was a DON for 10 years in a skilled facility prior to coming to work at VGM Education as an account executive. Deb provides educational consultation as well as authoring content and serving on the review board at VGM Education.
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Objectives:
• Locate resources including CDC templates for a comprehensive Infection Prevention and Control Program to individualize for any facility.
• Explain the process of completing the required annual facility infection control risk assessment; use this assessment to focus on specific areas for improvement.
• Discuss the reason for facility surveillance and how it impacts infection control. Share surveillance tools.
• Describe how to monitor medications utilized to treat infectious pathogens such as antibiotics, antivirals, and antifungals.
• Discuss the importance of tracking and trending data through analysis to impact utilization.
• Implement and report infection data at QA meetings.
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Why Should the Infection Control Process be Rebooted?1. To maintain processes during turnover and to allow others to help when necessary
2. To save time because the process remains consistent
3. To allow ongoing monitoring and efficiency through technology
4. To promote benchmarking and goal setting
5. To add consistent measures of data and to prevent gathering useless data
6. To encourage pharmacy involvement to the process
7. To reflect professionalism within the facility infection control efforts
8. To take the mystery out of infection control by involving all staff
9. To better encourage physician participation in the infection control process
10. To move infection control efforts from the office back to the bedside
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Current F-Tags Related to Infection Control• F880 – Infection Prevention and Control (included in handouts)
• A. Prevention and Control Program• B. Personal Protective Equipment• C. Infection Incident Reporting• D. Linen Handling• E. Annual Review
• F881 – Antibiotic Stewardship (included in handouts)
• F882 – Infection Preventionist Qualifications
• F883 – Influenza and Pneumococcal Vaccinations
• F884 – COVID Reporting to CDC
• F885 – COVID Reporting to Residents/Families
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What Are We Talking About Today?
• Focus is on F880 and F881
• With the enhanced emphasis on infection control, a facility must have safeguards for the continuity of its program.
• Infection preventionist(s)-make sure someone is designated to back-up when necessary
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Core Activities of Infection Prevention and Control Program
1. Developing and implementing policies and procedures
2. Conducting an annual review
3. Performing infection surveillance
4. Identifying, recording, and correcting infection prevention and control incidents
5. Establishing an Antibiotic Stewardship Program
6. Investigating and reporting communicable diseases
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Every Department Has a Role in the IPCP for the Facility
• Department managers need to maintain responsibility and accountability for the infection prevention and control activities of their departments.
• Department managers provide education to department staff on their role within the plan. Department heads can sign attestation documents annually that reflect that their policies are current and up to date and that their employees have completed required competencies.
• The goal is to have a program instead of having the infection preventionist as the exclusive person with knowledge of infection control.
• Consider combining QA&A meetings with the Infection Control Committee but make sure to separate minutes.
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Commonly Used Resources: Many Have Toolkits and/or Templates • CMS – regulations, care paths, infection control facility task (survey pathway)
• CDC – IP training, templates, specific releases such as Isolation Guidelines
• AHCA/state affiliates
• Leading Age/state affiliates
• APIC
• AHRQ-Infection Specific SBARs
• INTERACT – Stop and Watch, SBAR, Care Path
• OSHA
• Telligen – All Cause Harm Prevention; start with pages 32-35
• AMDA (now The Society for Post-Acute and Long-Term Care Medicine)
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What’s Good About Toolkits and Templates?
• They are already organized and written!
• They can usually be individualized.
• They are easy to insert into an established program.
• They can trigger thoughts of elements to include in your own program.
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What’s Bad About Toolkits and Templates?
• They often try to be a one-stop shop. Different sizes and types of facilities often require more specialized solutions.
• They are often modified from acute care tools. This can make them more complex than necessary. Gathering data that isn’t used or needed wastes time and effort.
• It’s sometimes difficult to sort out what is useful and then not use the rest, especially if it’s a coordinated program.
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Look For a Solution That is “Just Right”
• Builds on the needs of long-term care and especially your facility
• Collects information required by the regulations and by the facility
• Organizes data in a useful and productive manner
• Allows staff to see the value and contribute to the success
• Works efficiently saving staff time and effort
• Replicates easily
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F880
• 483.80 The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
• Achieving compliance is best for residents because it allows the identification of concerns consistently and as soon as possible.
• Compliance meets the highest clinical standards and best practices.
• Stresses the need for a comprehensive approach that meets the needs of the residents.
• Define the processes that can be achieved via technology and those that require the skills of the IP.
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F880
• 483.80(a) Infection prevention and control program.
• The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
• A program is ongoing with multiple elements. A set of related activities with a particular long-term aim. It includes policies and procedures as well as routine processes incorporated within the facility.
• A plan has goals and interventions designed to foster achievement of the goals within a certain amount of time. A detailed proposal for doing or achieving something. Think of a PDSA cycle. A simple example would be “Hand washing competency for 100% of new employees will be completed within the first day of orientation.”
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Attacking F880
• How do you effectively meet the requirements of F880?
• Infection control is the most cited deficiency in long-term care.
• As soon as you think you have it all figured out, reread the regulations to find something else you’ve missed! (And be sure to include the “intent” section in your reading.)
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Sub-Categories of F880
• 483.80(a)(1). A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards.
• Focus on the what: prevention, identification, reporting, investigating, and controlling
• Focus on the who: residents, staff, volunteers, visitors, and other individuals
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Sub-Categories of F880
• 483.80(a)(2). Written standards, policies, and procedures for the program, which must include, but are not limited to:
• (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility.
• Need for involvement by the whole facility
• Employee surveillance, visitor/vendor surveillance (think COVID-19)
• Consider tracking employee sick days per quarter
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What Might This Mean?
• Screening of visitors and employees
• Is it time to investigate technology solutions for these measures so we are ready when the pandemic emergency is lifted?
• Is your facility assessment up to date?
• Additional things to consider?
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Surveillance Is a Huge Topic and Difficult to Consistently Accomplish
• Note that the regulation states what must be included but then states “not limited to.” This makes compliance difficult.
• Line lists for surveillance
• The CDC has master Excel spreadsheet line lists for respiratory and GI cases.
• Complex data collection does not equal compliance.
• You need to identify who’s watching for what.
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Analyzing Surveillance Results Post COVID-19
• Primary surveillance indicator: fever.
• Primary surveillance question: “Are you feeling well today?” for all persons except residents.
• Primary surveillance for residents: temperature and change from baseline.
• INTERACT fever care path (included). If possible, use an additional care path if another indicator is present (included).
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Consider Using SBARs for Physician Notification
• INTERACT has a generic SBAR.
• AHRQ has developed SBARs specific to infection. Available templates include UTI, LRI, SSI, and GI.
• Provides physicians with consistent information to determine if an infection might be present.
• Enables documentation that infection criteria have been met.
• This also may justify antibiotic use.
• Consider if an assessment like this could be included in your electronic medical record.
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Why is Surveillance Important? Like We Don’t Know…
• Detects potential trends or outbreaks among groups of residents
• Identifies sepsis which can prevent resident deaths and facility liabilities
• Allows individual resident signs/symptoms identification and trend monitoring throughout the facility
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More on Surveillance
• As a rule, encourage over-reporting of potential infectious conditions. Infection surprises are never a good thing!
• Review the surveillance tool at routine intervals to analyze entries that are truly infections.
• What interventions are needed? Monitoring, non-pharmacologic approaches
• Medication interventions like antibiotics, antivirals, and antifungals. These should be logged. In fact, antibiotics must be logged.
• Analyzing and interpreting the surveillance results is a key requirement of the infection preventionist and requires the skills and special knowledge of that person.
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Sub-Categories of F880
• (ii). When and to whom possible incidents of communicable diseases or infections should be reported:
• Staff should report to the DON and/or IP for follow-up.
• Maintain a list of the reportable diseases from your state.
• Initiate and maintain contact with your local public health agency.
• State Department of Public Health – questions, guidance and reporting.
• If in doubt, report and document.
• Communication remains one of the most important tools in a good program.
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Sub-Categories of F880
• (iii) Standard and transmission-based precautions to be followed to prevent spread of infections:
• Most facilities offer only contact and droplet. Don’t forget the new type for MDROs and candida: enhanced barrier.
• During the pandemic, there was an additional type: special respiratory.
• Consider using the CDC template, “Selection and Use of Personal Protective Equipment During Standard Precautions” (included).
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Standard Precautions
As a reminder…
• All body fluids except sweat should not be touched with bare hands.
• Use appropriate PPE (gloves, gown, masks, eye protection) to avoid this contact.
• Religiously practice hand hygiene with alcohol-based hand sanitizers or by handwashing.
• Use safety needles and sharps.
• Practice respiratory etiquette by covering coughs in sleeves and wearing masks when recovering from coughs or colds.
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Clean Versus Dirty
• Take time to teach your staff (all staff) what is clean and what is dirty. Not understanding this is the basis of a huge number of deficiencies.
• These principles should be addressed through competency testing.
• Training is necessary for every staff member. Infection control is a required annual in-service topic.
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Transmission-Based Precautions
• Most facilities only offer contact and droplet precautions.
• Enhanced barrier precautions that fall between standard and contact precautions for residents colonized or infected with novel MDROs or other diseases such as candida
• Use CDC guidelines for type and duration based on specific diseases.
• Consider implementing both droplet and contact precautions until the cause of a cluster of similar illnesses is known.
• Immediately report any new respiratory or GI symptoms, especially if associated with a fever in any resident or employee.
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Sub-Categories of F880
• (iv) When and how isolation should be used for a resident; including but not limited to:
• (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
• (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
• Consider using CDC guidelines for this after determining disease type.
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Isolation Suggestions
• Isolation checklist to guide nursing staff (example included)
• Decide if placement is appropriate.
• Have isolation supplies easily obtainable.
• Communicate isolation status to all staff and family.
• Have reporting numbers available so notification calls can be easily accomplished if necessary.
• If transfer to a higher level of care becomes necessary, make sure that isolation status is communicated to the receiving facility.
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Sub-Categories of F880
• (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesion from direct contact with residents or their food, if direct contact will transmit the disease.
• Meet this regulation simply with a policy as a component of your employee health program.
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Sub-Categories of F880
• (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact.
• Your policy should address both handwashing and use of alcohol-based hand sanitizer.
• Consider the CDC template to meet this requirement.
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F880
• 483.80(a)(4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility.
1. Any case of sepsis or facility-acquired C. diff.
2. Any infection related to a medical device such as a catheter, feeding tube, trach, or vascular access device. (available in CMS-672)
3. Any order for an antibiotic that a resident has a documented allergy to.
4. Any physician- or nurse-ordered resident isolation.
5. Any active infection caused by a MDRO.
6. Flagrant breaches in established policy such as staff not wearing PPE in an isolation room might also be an incident.
• Educate staff that these should be treated as an incident with copies forwarded to the IP for follow-up and documentation and discussion at committee meetings.
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F880
• 483.80(e) Linens
• Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
• Meeting this requirement should be the responsibility of the laundry manager through department policies and procedures.
• The IP can provide input and monitor for compliance, as necessary.
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F880
• 483.80(f) Annual review.
• The facility will conduct an annual review of its IPCP and update their program, as necessary.
• Standing agenda items for QA and infection control meetings have helped. For example:o First quarter – IPCP review, IPCP all hazards
assessmento Second quarter – water plan, bloodborne
pathogen, sharps review
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F880
• 483.80(f) Annual review con’t
o Third quarter – respiratory protection plan, TB assessment
o Fourth quarter – antibiotic stewardship plan, competencies for IC
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F880 Further Defined in the “Intent” Section
1. Resident care activities
2. Environmental cleaning/disinfection
3. Written occupational health policies
4. Education and competency assessment
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Resident Care Activities – Required Policies/Procedures
• Urinary catheters
• Wound care, fecal/urinary incontinence care, and skin care
• Mechanical ventilation
• Infusion therapy
• Dialysis
• Performing finger sticks/point-of-care
• Preparation, administration and care for medications administered by injections or ports. Consider use of CDC Injection Safety Template
• Use and care of peripheral and central venous catheters
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Environmental Cleaning/Disinfection
• Staff education on product usage
• Medical equipment must be disinfected between use by different residents.
• Spaulding classification of medical equipment. Critical (sterile), semi-critical (cleaning/high-level disinfection), and noncritical (cleaning/low-level disinfection).
• Consider using CDC Environmental and Disinfection Template
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Written Occupational Health Policies
• Bloodborne Pathogens
• Sharps evaluation
• Sick leave
• Hepatitis B program
• Key Note- include statement prohibiting employees with communicable disease or infected skin lesion from direct contact with residents.
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Education and Competency Assessment
• CMS competency assessments for CNA/CMTs, LPN/LVN, RN, and Administrator/DON/ADON
• Skills fairs are used at a lot of homes with return demonstration.
• Vendors, especially food and housekeeping supply vendors, often can provide competency assessment tools for those specific departments.
• One goal is to sometime link competency assessments to staff evaluations. Can you do this in your facility? It might make your job easier.
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F881
• 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program that must include, at a minimum, the following elements:
• 483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
• Consider using the CDC Antibiotic Stewardship guidance to write your policy.
• Antibiotic stewardship has an emphasis on oral antibiotics, and this is the data that requires collection. This is different from the MDS that also counts ointments and/or drops.
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What Do We Already Know?
• Antibiotics can be life-saving when used appropriately.
• Antibiotics can be life-threatening when used inappropriately.
• Inappropriate or overuse of antibiotics can lead to the growth of resistant organisms which can threaten not only the resident, but also the community.
• Antibiotic monitoring is most easily accomplished through use of technology.
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Antibiotic Use Protocols We Use
• No prophylactic antibiotic use related to urinary tract infections for more than 30 days without a consult with a urologist.
• No re-culture of urine following a course of antibiotics without individual recorded justification by the physician.
• No prophylactic antibiotic use related to respiratory infections for more than 30 days without a consult by a pulmonologist.
• No recurrent antibiotic use related to a skin/soft tissue infection without an ET consult and/or culture.
• All antibiotics will be reassessed 48-72 hours after initiation by a professional nurse.
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System to Monitor Antibiotic Use: Requirements
• Antibiotic use data must “contain a system of reports related to monitoring antibiotic usage and resistance data.”
• Also include a method of providing feedback to prescribing practitioners regarding antibiotic use.
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System to Monitor Antibiotic Use: Requirements
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System to Monitor Antibiotic Use: Requirements
• This can include the rate of new starts, types of antibiotics prescribed, or days of antibiotic treatment per 1,000 days.
• An assessment of residents for infection using standardized tools and criteria such as Loeb Minimum Criteria for the initiation of antibiotics and SBAR for physician notification.
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System to Monitor Antibiotic Use: Requirements
• Monitors for trends in antibiotic use over specified periods of time.
• Allows facility to set benchmarks to determine progress.
• Ability to focus on areas of interest or concern.
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In Summary…
• Annually review and update:
• Each department’s infection control policies and procedures Consider attestation statements to spread responsibility and accountability
• All appropriate employee competencies and/or competency statements
• Infection control all-hazards assessment *
• TB assessment *
• Infection control plan with thresholds
• Updated list of reportable diseases specific to your state
• Updated copies of vaccine information sheets and/or Emergency Use Authorizations given to residents related to vaccines administered at the facility
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Annual Review, Cont.
• Respiratory protection program
• Sharps safety assessment
• Water program
• Emergency plan (related to pandemic readiness especially)
• Competency statements from department heads
• Infection control manual
• Antibiotic stewardship plan
• Antibiogram
• Antibiotic use protocols
• Occupational Health including blood borne pathogens, Hepatits B, etc
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Quarterly Activities and Documentation
• Copies of any lab work related to infections (if available and/or necessary)
• Physician notification of antibiotic use for the quarter *
• Employee illness log
• Surveillance line lists
• Infection control incident reports
• List of medical devices in use for the quarter (HCFA 672)
• Antibiotic use for the quarter, as well as antiviral and antifungal use, if available (helpful if in a case log format, if possible, for easier analysis) *
• C. diff reporting *
• Tracking and trending reports*
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Final Thoughts……
• To be effective, your IPCP must be a logical, reproducible process. Set up systems and complete them routinely.
• Automate whenever possible, especially with data collection.
• Use established principles as a basis for your program.
• Educate and involve staff because you truly can’t be successful trying to do it all by yourself.
• But always be willing to do just as much as your staff does.
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Be the Chick With the Infection Control Answers“C’mon germs, you wanna piece of this?”
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References
• https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
• https://www.livescience.com/64280-chickens-taking-over-world.html
• CMS QSO 20-12-ALL March 4, 2020
• www.ahrq.gov/NH-ASPguide June 2014
• Infection Compliance Solutions Tool V.2, VGM, CE Solutions
• https://apic.org/resources/topic-specific-infection-prevention/long-term-care/
• https://pathway-interact.com/
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Thanks for your attendance and participation!
Sue Ayers [email protected]
Deb Martin [email protected]
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©2011 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.
Version 4.0 Tool
CARE PATH Fever
YES
Manage in Facility• Monitor vital signs, fluid intake/urine output every 4-8 hrs for 24-72 hrs• Do not give acetaminophen unless necessary for comfort
(it can mask fever), or until source of fever known• If on diuretic, consider holding• Oral, IV or subcutaneous fluids if needed for hydration• Update advance care plan and directives if appropriate
Take Vital Signs• BP, pulse, apical HR (if pulse irregular)• Respirations• Oxygen saturation• Finger stick glucose (diabetics)
Vital Sign Criteria (any met?)• Temp > 100.5˚F• Apical heart rate > 100 or < 50• Respiratory rate > 28/min or < 10/min• BP < 90 or > 200 systolic
• Oxygen saturation < 90%• Finger stick glucose < 70 or > 300• Resident unable to eat or drink
Consider Contacting MD/NP/PAfor orders (for furtherevaluation and management)• Portable chest X-ray• Urinalysis and C&S if indicated• Blood work (Complete Blood Count, Basic Metabolic Panel) • Stool specimen for culture and C. Difficile assay (diarrhea)• Nasal Pharyngeal swab for influenza
YES
YESNO
NO
Notify MD / NP / PA
TestsOrdered
EvaluateResults• Critical values in blood
count or metabolic panel• WBC > 14,000 or
neutrophils > 90%• Infiltrate or pneumonia
on chest X-ray• Positive C. Diff• Positive flu result on swab• Urine results suggest
infection and symptoms or signs present
Fever Definition• One temp > 100˚F ( > 37.8˚C )• Two temps > 99˚F ( > 37.2˚C ) oral or > 99.5˚F ( > 37.5˚C ) rectal• Increase in temp of 2˚F ( 1.1̊ C ) over baseline
Evaluate Symptoms and Signs for Immediate Notification*• Acute mental status change• Not eating or drinking• Acute decline in ADL abilities• New cough, abnormal lung sounds• Nausea, vomiting, diarrhea• Abdominal distension or tenderness
• New or worsened incontinence, pain with urination, blood in urine
• Very low urinary output• New skin condition (e.g. rash, redness
suggesting cellulitis, signs of infection around existing wound/pressure ulcer)
• Unrelieved pain
* Refer also to other INTERACT Care Paths as indicated by symptoms and signs
NO
YES
MonitorResponse• Vital signs criteria met• Worsening condition and/or immediate notification
criteria met
