Reporting Community Onset CDI

January 13, 2016
by Heather Dubendris, MSPH, North Carolina Department of Health and Human Servicesicon-reporting

In early 2015, the North Carolina Division of Public Health (NC DPH) Healthcare-Associated Infection (HAI) Prevention Program initiated a consultative, non-regulatory validation of central line-associated bloodstream infection (CLABSI) and C. difficile infection (CDI) data reported through the National Healthcare Safety Network (NHSN). The purpose of this validation is to help hospitals improve the identification and reporting of CLABSI and CDI. This validation is ongoing; aggregate results will be made available upon completion of validation activities. In addition to quality assurance, validation also presents important opportunities to identify and address any areas for improvement. One immediate area of improvement that we have identified is the failure to report community onset CDI events (CO CDI) through NHSN. CO CDI events do not appear in the total count of CDI attributed to your facility. However, these events are used to assess the burden of CDI within your community and are one factor used to risk-adjust the standardized infection ratio (SIR) for your facility. If you do not report CO CDI, your facility’s risk adjustment will not be accurate.

Please note that this is not a change in reporting requirements, but applies only to those units facilities are currently required to report from FACWIDEIN (which includes all inpatient locations and as of 2015 also requires facilities to include location specific reporting for Emergency Departments and 24-hour observation locations). Facilities do not need to report positive CDIs that come from outside of their inpatient, ED and observation units.

The 2015 NHSN definition of laboratory identified (LabID) CDI is provided below for reference. Additional information is available here.

CDI-positive laboratory assay: A positive laboratory test result for C. difficile toxin A and/or B, (includes molecular assays [PCR] and/or toxin assays) tested on an unformed stool specimen (must conform to the container) OR A toxin-producing C. difficile organism detected by culture or other laboratory means performed on an unformed stool sample (must conform to the container).

CDI Data Analysis: Based on data provided on the LabID Event form, each event will be categorized by NHSN to populate different measures. By classifying positive cultures obtained on day 1 (admission date), day 2, and day 3 of admission as CO LabID Events and positive cultures obtained on or after day 4 as HO LabID Events. All HO LabID Events will have occurred more than 48 hours after admission.

CDC Urges Hospitals to Review Reprocessing Procedures for Medical and Surgical Devices

November 30, 2015
by William A. Rutala, Ph.D., M.P.H.
Endoscope Processing
Endoscope Reprocessing

In the United States in 2010 there were approximately 51.4 million inpatient surgical procedures and an even larger number of invasive medical procedures.(1) In 2009, there were over 6.9 million upper GI, 11.5 million lower GI and 228,000 biliary endoscopies performed.(2) Each of these procedures involves contact by a medical device or surgical instrument with a patient’s sterile tissue or mucous membranes. A major risk of all such procedures is the introduction of pathogenic microbes, which can lead to infection. Failure to properly disinfect or sterilize equipment may lead to transmission via contaminated medical and surgical devices (e.g., carbapenem-resistant Enterobactericeae [CRE]).(3,4)

Achieving disinfection and sterilization through the use of disinfectants and sterilization practices is essential for ensuring that medical and surgical instruments do not transmit infectious pathogens to patients. Since it is not necessary to sterilize all patient-care items, healthcare policies must identify whether cleaning, disinfection, or sterilization is indicated based primarily on each item’s intended use.

Multiple studies in many countries have documented lack of compliance with established guidelines for disinfection and sterilization. Failure to comply with scientifically-based guidelines has led to numerous outbreaks and patient exposures.(3-8) Recent infection control lapses due to non-compliance with recommended reprocessing procedures highlight the importance of medical device reprocessing. To address this patient safety issue, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) issued a health advisory alerting healthcare providers and facilities about the public health need to properly maintain, clean, and disinfect and sterilize reusable medical devices.(9)

To facilitate a review of your healthcare facilities reprocessing practices and implementation of this CDC Health Advisory, we have prepared a high-level disinfection/sterilization audit checklist. This checklist was prepared using CDC and guidelines from professional organizations.(10) It is provided to you for information only. The Infection Preventionist, or another healthcare professional with expertise in device reprocessing, should assess their reprocessing procedures and may find this checklist useful. Read More →

High-level Disinfection/Sterilization Audit Checklist Available

November 30, 2015
checklist image
Checklist page 1 of 11
by William A. Rutala, Ph.D., M.P.H.

As noted above, to facilitate a review of your healthcare facilities reprocessing practices and implementation of this CDC Health Advisory, we have prepared a high-level disinfection/sterilization audit checklist. It is provided to you for information only. The Infection Preventionist, or another healthcare professional with expertise in device reprocessing, should assess their reprocessing procedures and may find this checklist useful. Link to the checklist.

Middle East Respiratory Syndrome

November 30, 2015
by David Weber, M.D., M.P.H.

The Middle East Respiratory Syndrome (MERS) is a new viral respiratory disease of humans first described in 2012. MERS is caused by a novel coronavirus (lineage 2C β CoV ).MERS-CoV

As of 25 September 2015 the following countries in the Middle East have reported cases: Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates (UAE), and Yemen. Countries with travel-associated cases have included Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Republic of Korea, Thailand, Turkey, United Kingdom (UK), and the United States. The U.S. has had only 2 travel-associated cases, both of whom were healthcare providers who lived and worked in Saudi Arabia. No person-to-person transmission has been documented in the U.S.

WHO MERSMERS-CoV is a zoonotic disease that it transmitted from animals-to-humans. The origins of the virus are not fully understood but it is believed to have originated in bats and then was transmitted to camels. Currently, it is believed that dromedary (single-humped) camels are a major reservoir host for MERS-CoV and an animal source for humans.

MERS may be transmitted from person-to-person: this occurs most commonly when there is close contact such as providing unprotected care to an infected patient. Thus far, no sustained community transmission has been documented. The Ro for MERS-CoV is generally estimated to less than 0.7 making sustained transmission unlikely unless it mutates. Studies of family clusters and healthcare personnel contacts of patients have reported low frequencies of transmission (i.e., 1-3%). The incubation period of MERS is ~5-day (range, 2-15 days).

MERS has been epidemic in the Middle East in recent years. As of 11 September 2015, the World Health Organization has reported a total of 1,583 confirmed cases of MERS with 566 deaths.

In the summer of 2015, a large outbreak of MERS was reported in the Republic of Korea and China. As of 11 September, the World Health Organization reported that this outbreak involved 186 total confirmed cases (Republic of Korea 185, China 1) with 36 deaths. The last case of MERS infection in the Republic of Korea that was reported to the WHO was on 4 July 2015.

Clusters of cases have been reported in households and in healthcare facilities, especially when infection prevention and control practices have been inadequate.

The clinical spectrum of MERS infection ranges Read More →

Legionella Toolkit Available

November 30, 2015
by NC Division of Public Health Healthcare-Associated Infections Prevention Program

Outbreaks of Legionella in NC long term care facilities (LTCF) were discussed in the April 2015 edition of the Infection Control Report. Legionnaires’ disease (LD) is a severe multisystem illness caused by Legionella LD Tool Kitbacteria and characterized by pneumonia, cough, fever, and muscle aches. Legionella bacteria are found in man-made and natural aquatic environments and are transmitted by inhalation of aerosolized water colonized with the bacteria. The risk of LD after exposure to Legionella bacteria depends on the type of exposure and the health status of the exposed person. Risk factors for LD include age older than 50 years, use of respiratory equipment (e.g., nebulizers), and the presence of immunocompromising conditions, especially chronic lung disease.

Since the last blog, DPH has published a Legionellosis Prevention and Response Toolkit for use in facilities. This toolkit was created in response to multiple cases and outbreaks of healthcare-associated Legionellosis across North Carolina during 2014. This information can be accessed under the disease listing “Legionella” at: . Although the materials are geared toward long-term care facilities, many of the principles are also applicable to acute care settings.

CDC Releases Core Elements of Antibiotic Stewardship in Nursing Homes

November 30, 2015
by Kirk Huslage, R.N., B.S.N., M.S.P.H., C.I.C.
CDC Antibiotic
from CDC: The Core Elements of Antibiotic Stewardship for Nursing Homes

Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics in a year. Similar to the findings in acute care hospitals, studies have shown that 40%-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate.

This high level of exposure to antibiotics can lead to serious adverse events and consequences for the individual and the community, such as Clostridium difficile, (C diff) infections, drug-drug interactions, and colonization or infection with antibiotic-resistant organisms.

To support nursing home efforts to improve antibiotic use, CDC published a new resource, CDC Core Elements of Antibiotic Stewardship for Nursing Homes. The guide provides examples of how antibiotic use can be monitored and improved by nursing home leadership and staff. The companion checklist can be used to assess policies and practices that are in place and to review progress in expanding stewardship activities on a regular basis.

The core elements of antibiotic stewardship are the same for both hospitals and nursing homes; however, facilities may have differences in the implementation of these elements. Nursing home antibiotic stewardship activities should, at a minimum, include seven basic elements:

  1. Leadership commitment through demonstration of a facility’s support of safe and appropriate antibiotic use
  2. Accountability through identification of leaders responsible for promoting and overseeing stewardship activities
  3. Drug expertise in antibiotic use and stewardship
  4. Action to implement the recommended policies or practices to improve use, such as requiring an “antibiotic time-out” or review for all new antibiotic prescriptions
  5. Tracking measures of antibiotic use practices and outcomes
  6. Reporting data on antibiotic prescribing and appropriateness of use to facility staff
  7. Education for clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improving use

Nursing homes are encouraged to work in a step-wise fashion to expand their stewardship efforts. As policies and practices are successfully implemented, new strategies can be added to ensure that, over time, activities for each element are put into place. Any action to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in nursing homes.

Article of Interest:

Optimizing Antibiotic Stewardship in Nursing Homes:  A Narrative Review and Recommendations for Improvement


Regulatory and Policy Updates

November 30, 2015
by Kirk Huslage, R.N., B.S.N., M.S.P.H., C.I.C.

CDC and FDA Alert Facilities to Review Procedures for Device Reprocessing

The U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) issued a health alert advising healthcare providers and facilities about the public health need to properly whats_newmaintain, clean, and disinfect or sterilize reusable medical devices. Recent lapses in compliance with recommended reprocessing procedures have led to increasing numbers of patient notifications about possible exposures. Please share this information with your facilities and colleagues. Read the CDC/FDA alert.

CDC and FDA Alert Facilities About Need for Increased Vigilance for Non-tuberulosis Mycobacterium (NTM) Infections Related to Heater-Cooler Devices 

CDC has identified a need for increased vigilance for NTM infections by health departments, healthcare facilities, and individual healthcare providers. FDA recently issued a Safety Communication on Nontuberculous Mycobacterium Infections Associated with Heater-Cooler Devices that addresses issues regarding the proper use and maintenance of these devices. CDC has been working with the FDA and local and state health departments to investigate heater-cooler units associated with NTM infections and/or found to be contaminated with NTM. This CDC communication is to (a) raise awareness among health departments, healthcare facilities, and healthcare providers of the possible association between NTM infections and use of heater-cooler devices and (b) to provide guidance on identifying patients with infection.  Read the CDC memo  Read the FDA alert

CDC and CMS Issue Joint Reminder on Adherence to NHSN Reporting Criteria

The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) issued a joint reminder to National Healthcare Safety Network (NHSN) users and hospital administrators reiterating the importance of adherence to CDC healthcare-associated infection (HAI) definitions. This communication is in response to occasional reports from infection preventionists and others about challenges within facilities when some decisions about what infections should be reported to NHSN are made by individuals who may choose to disregard CDC’s protocol, definitions and criteria, or who may not be thoroughly familiar with the NHSN specifications. APIC has created a Q and A on the document that is helpful, but it is important to read the complete communication from CDC and CMS to best understand how it can help IPs inform their facilities.

CMS Releases Update to Ambulatory Surgical Center (ASC) Infection Control Surveyor Worksheet

The Centers for Medicare & Medicaid Services (CMS) has made minor revisions to the Infection Control Surveyor Worksheet, Exhibit 351 of the State Operations Manual (SOM) for assessing compliance with the Medicare ASC Infection Control Condition for Coverage (CfC). Revisions were made to bring the worksheet into alignment with current accepted standards of practice; reflect recently released guidance; and improve the clarity of certain questions. The worksheet is used by State and Federal surveyors on all survey activity in ASCs when assessing compliance with the infection control CfC.  Read the CMS S&C memo

One & Only Injection Safety Campaign: Drug Diversion

November 30, 2015
by NC Division of Public Health Healthcare-Associated Infections Prevention Program

The North Carolina Division of Public Health (NC DPH) is engaging stakeholders in an effort to increase awareness of drug diversion and its consequences for patient safety. This effort is being undertaken as part of our drug diversionrole as a state member of the One & Only Injection Safety Campaign. When prescription medications are obtained or used illegally by healthcare workers, it puts patients, health care workers, and employers at risk. Diversion involving injectable medications or injection equipment has been linked to multiple outbreaks of bacterial and viral infections nationwide, including six outbreaks reported to CDC between 2004 and 2014 that collectively resulted in more than 100 infections and 30,000 potential exposures.  To date, no outbreaks or infections linked to drug diversion have been reported in North Carolina.

On August 18th, NC DPH held our initial Drug Diversion Workgroup meeting. This meeting brought together various experts from law enforcement agencies, professional licensing boards and other professional groups. Going forward, our goal is to identify and promote best practices for drug diversion detection, prevention, and response that can be used by healthcare facilities statewide. We are also working to insure that public health agencies are notified when diversion is identified that involves injectable medications or injection supplies so that a thorough assessment of infection risks can be conducted.

New CMS Proposed Rule to Revise Long-term Care Facility Requirements for Medicare and Medicaid Program Participation

November 30, 2015
by Kirk Huslage, R.N., B.S.N., M.S.P.H., C.I.C.

On July 13, 2015, the Centers for Medicare & Medicaid (CMS) issued a long-awaited proposed rule (Proposed Rule) that would revise the requirements that long-term care (LTC) facilities must meet to participate in the Medicare and Medicaid programs.  The Proposed Rule represents the first comprehensive change to the conditions of participation (CoPs) since 1991. As CMS notes, the population of nursing homes has changed substantially since 1991 — becoming more diverse and more clinically complex. CMS stated that the revisions were generally aimed at aligning requirements with current clinical practice standards to improve resident safety along with the quality and effectiveness of care and services delivered to residents.

The Proposed Rule includes a substantial expansion of infection prevention and control requirements

  • Requirements for the facility to perform a facility-specific assessment of their resident population and facility (§ 483.70)
  • Integration of the infection prevention and control program (IPCP) with the facility’s QAPI processes (§ 483.75)
  • Revising the description of the infection control program and adding a requirement to periodically review and update the program (§ 483.80)
  • Requiring an antibiotic stewardship program that includes antibiotic use protocols and a system for monitoring antibiotic use (§ 483.80)
  • Designation of specific infection prevention and control officers (IPCOs) (§ 483.80)
  • Written policies and procedures for the IPCP (§ 483.80)
  • Education or training related to the infection control program (§ 483.80)

CMS generally implements changes to regulatory requirements for survey and certification processes within twelve months of the final rule publication; however, given the scope and complexity of these revisions, many commenting organizations have requested a 3-5 year implementation to allow facilities adequate opportunity to make the required changes.