Update on the Infection Control and Antimicrobial ... · efforts to improve antibiotic use (antibiotic stewardship). 27% 73% 15% 85% B. The facility has identified individuals accountable

ARKANSAS DEPARTMENT OF HEALTH


Statewide Antimicrobial Stewardship Initiative (SASI)

Rohan Chakravorty, MPH

Infection Control Assessment and Response (ICAR)and

An ADH Update


Objectives

• Discuss the scope and purpose of the ICAR and SASI programs

• Present the population demographics currently assessed

• Review the outcomes facility assessments


ICAR Assessments

• Texas Presbyterian - 1st Ebola patient Sept 2014

• New initiative funded by Centers for Disease

Control and Prevention

• On-site visits to assess infection control program

and provide guidance and resources

• 3 C’s: No Cost, Collaborative, and Confidential

• Data are being collected statewide and

nationally to develop education and programs to

mitigate common gaps


ICAR Assessments

1. Increase infection control capacity around the state

2. Improve efforts to prevent Healthcare Associated Infections and antibiotic resistant infections

3. Build collaboration and communication between ADH and facilities


Scope - CDC Assessment Tool

Topics include:Program Infrastructure

Resident Safety

Hand Hygiene

Personal Protective Equipment

Respiratory Etiquette

Antibiotic Stewardship

Injection Safety

Environmental Cleaning


Cumulative Infection Control Assessment and Readiness (ICAR) Visits Conducted in Arkansas through April 2019, by Facility Type

Unpublished aggregate data. Not intended for public use.


Infection Control Program and Infrastructure

Small Facility <100 beds Large Facility >100 bedsn=11 n=34

%no %yes %no %yesA. The facility has specified a person (e.g., staff, consultant) who is responsible for coordinating the IC program.

0% 100% 0% 97%

B. The person responsible for coordinating the infection prevention program has received training in IC

55% 45% 76% 24%

C. The facility has a process for reviewing infection surveillance data and infection prevention activities (e.g., presentation at QA committee).

55% 45% 0% 100%

D. Written infection control policies and procedures are available and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations (F-441), or standards.

0% 100% 3% 97%

E. Written infection control policies and procedures are reviewed at least annually or according to state or federal requirements, and updated if appropriate.

18% 82% 6% 94%

F. The facility has a written plan for emergency preparedness (e.g., pandemic influenza or natural disaster).

0% 100% 3% 97%


Healthcare PersonnelSmall Facility <100 beds Large Facility >100 beds

n=11 n=34% No % Yes % No % Yes

A. The facility has work-exclusion policies concerning avoiding contact with residents when personnel have potentially transmissible conditions which do not penalize with loss of wages, benefits, or job status.

10% 90% 15% 85%

B. The facility educates personnel on prompt reporting of signs/symptoms of a potentially transmissible illness to a supervisor

0% 100% 0% 100%C. The facility conducts baseline Tuberculosis (TB) screening for all new personnel 0% 100% 0% 100%D. The facility has a policy to assess healthcare personnel risk for TB (based on regional, community data) and requires periodic (at least annual) TB screening if indicated.

0% 100% 3% 97%

E. The facility offers Hepatitis B vaccination to all personnel who may be exposed to blood or body fluids as part of their job duties

18% 82% 9% 91%F. The facility offers all personnel influenza vaccination annually. 0% 100% 0% 100%G. The facility maintains written records of personnel influenza vaccination from the most recent influenza season. 9% 91% 3% 97%H. The facility has an exposure control plan which addresses potential hazards posed by specific services provided by the facility (e.g., blood-borne pathogens).

9% 91% 3% 97%

I. All personnel receive training and competency validation on managing a blood-borne pathogen exposure at the time of employment.

64% 36% 18% 82%

J. All personnel received training and competency validation on managing a potential blood-borne pathogen exposure within the past 12 months.

64% 36% 24% 76%


Resident SafetySmall Facility <100 beds Large Facility >100 beds

n=11 n=34

% No % Yes % No % Yes

A. The facility currently has a written policy for to assess risk for TB (based on regional, community data) and provide screening to residents on admission.

0% 100% 0% 100%

B. The facility documents resident immunization status for pneumococcal vaccination at time of admission.

0% 100% 0% 100%

C. The facility offers annual influenza vaccination to residents. 0% 100% 0% 100%


SurveillanceSmall Facility <100 beds Large Facility >100 beds


A. The facility has written intake procedures to identify potentially infectious persons at the time of admission.

45% 55% 21% 79%

B. The facility has system for notification of infection prevention coordinator when antibiotic-resistant organisms or C.difficile are reported by clinical laboratory.

0% 100% 0% 100%

C. The facility has a written surveillance plan outlining the activities for monitoring/tracking infections occurring in residents of the facility.

9% 91% 6% 94%

D. The facility has system to follow-up on clinical information, (e.g., laboratory, procedure results and diagnoses), when residents are transferred to acute care hospitals for management of suspected infections, including sepsis.

18% 82% 24% 76%


Disease ReportingSmall Facility <100 beds Large Facility >100 beds

n=11 n=34


A. The facility has a written plan for outbreak response which includes a definition, procedures for surveillance and containment, and a list of syndromes or pathogens for which monitoring is performed.

73% 27% 39% 61%

B. The facility has a current list of diseases reportable to public health authorities.

36% 64% 18% 82%

C. The facility can provide point(s) of contact at the local or state health department for assistance with outbreak response.

55% 45% 24% 76%


Hand HygieneSmall Facility <100 beds Large Facility >100 beds

n=11 n=34


A. The facility hand hygiene (HH) policies

promote preferential use of alcohol-based

hand rub over soap and water except when

hands are visibly soiled (e.g., blood, body

fluids) or after caring for a resident with

known or suspected C. difficile or norovirus.

9% 91% 6% 94%

B. All personnel receive training and

competency validation on HH at the time of

employment.45% 55% 38% 62%

C. All personnel received training and

competency validation on HH within the past

12 months.36% 64% 21% 79%

D. The facility audits (monitors and

documents) adherence to HH73% 27% 62% 38%

E. The facility provides feedback to

personnel regarding their HH performance.64% 36% 47% 53%

F. Supplies necessary for adherence to HH

(e.g., soap, water, paper towels, alcohol-based

hand rub) are readily accessible in resident

care areas (i.e., nursing units, resident rooms,

therapy rooms).

9% 91% 3% 97%


Personal Protective EquipmentSmall Facility <100 beds Large Facility >100 beds

n=11 n=34

% No % Yes % No % YesA. The facility has a policy on Standard

Precautions which includes selection and use of PPE (e.g., indications, donning/doffing procedures).

0% 100% 3% 97%

B. The facility has a policy on Transmission-

based Precautions that includes the clinical conditions for which specific PPE should be used (e.g., C.diff, Influenza).

9% 93% 6% 94%

C. Appropriate personnel receive job-

specific training and competency validation on proper use of PPE at the time of employment.

73% 27% 48% 52%

D. Appropriate personnel received job-

specific training and competency validation on proper use of PPE within the past 12 months.

64% 36% 39% 61%

E. The facility audits (monitors and

documents) adherence to PPE use (e.g., adherence when indicated, donning/doffing).

64% 36% 73% 27%

F. The facility provides feedback to

personnel regarding their PPE use.64% 36% 67% 32%

G. Supplies necessary for adherence to

proper PPE use (e.g., gloves, gowns, masks) are readily accessible in resident care areas (i.e., nursing units, therapy rooms).

9% 91% 0% 100%


Respiratory/Cough EtiquetteSmall Facility <100 beds Large Facility >100 beds


A. The facility has signs posted at entrances with instructions to individuals with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?

45% 55% 42% 58%

B. The facility provides resources for performing hand hygiene near the entrance and in common areas.

18% 82% 36% 64%

C. The facility offers facemasks to coughing residents and other symptomatic persons upon entry to the facility.

18% 82% 42% 58%

D. The facility educates family and visitors to notify staff and take appropriate precautions if they are having symptoms of respiratory infection during their visit?

27% 73% 18% 82%

E. All personnel receive education on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens

0% 100% 6% 94%


Antibiotic StewardshipSmall Facility <100 beds Large Facility >100 beds


A. The facility can demonstrate leadership support for efforts to improve antibiotic use (antibiotic stewardship). 27% 73% 15% 85%B. The facility has identified individuals accountable for leading antibiotic stewardship activities 36% 64% 9% 91%C. The facility has access to individuals with antibiotic prescribing expertise (e.g. ID trained physician or pharmacist). 73% 27% 88% 12%D. The facility has written policies on antibiotic prescribing. 82% 18% 56% 44%E. The facility has implemented practices in place to improve antibiotic use. 82% 18% 32% 68%F. The facility has a report summarizing antibiotic use from pharmacy data created within last 6 months. 73% 27% 53% 47%G. The facility has a report summarizing antibiotic resistance (i.e., antibiogram) from the laboratory created within the past 24 months.

82% 18% 65% 35%H. The facility provides clinical prescribers with feedback about their antibiotic prescribing practices. 91% 9% 65% 35%I. The facility has provided training on antibiotic use (stewardship) to all nursing staff within the last 12 months. 91% 9% 47% 53%J. The facility has provided training on antibiotic use (stewardship) to all clinical providers with prescribing privileges within the last 12 months.

100% 0% 85% 15%


Injection SafetySmall Facility <100 beds Large Facility >100 beds


A. The facility has a policy on injection safety which includes protocols for performing finger sticks and point of care testing (e.g., assisted blood glucose monitoring, or AMBG).

18% 82% 3% 97%

B. Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures at time of employment.

45% 55% 32% 68%

C. Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures within the past 12 months.

64% 36% 53% 47%

D. The facility audits (monitors and documents) adherence to injection safety procedures during point of care testing (e.g., AMBG).

55% 45% 45% 55%

E. The facility provides feedback to personnel regarding their adherence to injection safety procedures during point of care testing (e.g., AMBG).

64% 36% 36% 64%

F. Supplies necessary for adherence to safe injection practices (e.g., single-use, auto-disabling lancets, sharps containers) are readily accessible in resident care areas (i.e., nursing units).

0% 100% 0% 100%

G. The facility has policies and procedures to track personnel access to controlled substances to prevent narcotics theft/drug diversion.

9% 91% 3% 97%


Environmental CleaningSmall Facility <100 beds Large Facility >100 beds


A. The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of resident rooms.

9% 91% 6% 94%B. The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of rooms of residents on contact precautions (e.g., C. diff).

0% 100% 6% 94%C. The facility has written cleaning/disinfection policies which include cleaning and disinfection of high-touch surfaces in common areas.

18% 82% 9% 91%D. The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.).

36% 64% 15% 85%

E. Facility has policies and procedures to ensure that reusable medical devices (e.g., blood glucose meters, wound care equipment, podiatry equipment, dental equipment) are cleaned and reprocessed appropriately prior to use on another patient.

18% 82% 13% 87%

F. Appropriate personnel receive job-specific training and competency validation on cleaning and disinfection procedures at the time of employment.

36% 64% 24% 76%G. Appropriate personnel received job-specific training and competency validation on cleaning and disinfection procedures within the past 12 months.

45% 55% 38% 62%H. The facility audits (monitors and documents) quality of cleaning and disinfection procedures. 45% 55% 38% 62%I. The facility provides feedback to personnel regarding the quality of cleaning and disinfection procedures. 36% 64% 30% 70%J. Supplies necessary for appropriate cleaning and disinfection procedures (e.g., EPA-registered, including products labeled as effective against C.difficile and Norovirus) are available.

0% 100% 6% 94%



Summary of SASI Data


Statewide Antimicrobial Stewardship Initiative (SASI)

Three foundational principles:1. Voluntary2. Non-regulatory3. Confidential


Facility Statistics

• 36 Facilities Visited

– December 2017 – May 2019

– 35 Hospitals

• 12 Critical Access Hospitals (including SHIP hospitals)

• 23 General Acute Care Hospitals

– 1 Long-Term Care Facility


Facility Statistics (cont’d)

• Locations*

– 9 – Northwest Arkansas

– 9 – Northeast Arkansas

– 8 – Central Arkansas

– 3 – Southwest Arkansas

– 6 – Southeast Arkansas

(*One “facility” consisted of multiple regional facilities of a hospital system)


Example page from SASI Tool


LeadershipGeneral Hospital (n=23) Critical Access (n=12)

No (%) Yes (%) No (%) Yes (%)

1. Facility has written policy that identifies antimicrobial resistance as a major medical issue and supports having an ASP in order to prevent the spread of antimicrobial resistance and improve patient care.

9 91 8 92

2. The written policy identifies the ASP job duties that are to be undertaken. 22 78 25 75

3. The written policy specifies the dedicated time to be given to healthcare personnel for completion of ASP job duties.

74 26 100 0

4. The written policy supports the need for continuing education and training related to antimicrobial stewardship.

61 39 42 58

5. The written policy emphasizes having an interdisciplinary team to support antimicrobial stewardship activities.

13 87 25 75


AccountabilityGeneral Hospital (n=23) Critical Access (n=12)

No (%) Yes (%) No (%) Yes (%)1. Facility has single, dedicated and engaged leader to take responsibility of the ASP.

4 95 0 100

2. ASP Leader is a: Physician 83 17 83 17

Pharmacist 17 83 17 83Other 100 0 100 0

3. ASP leader has residency/fellowship ID training. 91 9 100 0

a. If no, leader has completed an ID certificate training program (MAD-ID, SIDP, Stanford Online, etc.)

61 39 75 25

MAD-ID 91 9 92 8SIDP 74 26 92 8

Other 91 9 92 8

4. ASP leader is involved with direct patient care on a regular basis. 26 74 17 83

5. ASP leader is on call 24/7 for antimicrobial stewardship related issues.

61 39 33 67


Drug ExpertiseGeneral Hospital (n=23) Critical Access (n=12)

No (%) Yes (%) No (%) Yes (%)1. Facility has full-time, onsite pharmacist(s). 4 96 8 92

2. Facility has single, dedicated pharmacist to monitor and review appropriate antibiotic use.

13 87 0 100

3. Dedicated pharmacist has residency/fellowship ID training. 78 22 92 8

a. If no, pharmacist has completed an ID certificate training program (MAD-ID, SIDP, Stanford Online, etc.)

30 70 58 42

MAD-ID 83 17 92 8SIDP 48 52 75 25

Other 96 4 92 84. Location of pharmacist is centralized to the pharmacy or de-centralized to the floor.

De-centralized 48 52 92 8Centralized 52 48 8 92


ActionsGeneral Hospital (n=23) Critical Access (n=12)

No (%) Yes (%) No (%) Yes (%)

1. Facility has written policy for restriction or prior authorization before usage on specific antimicrobial agents 43 57 58 42

2. Facility has written policy to regularly review antimicrobial agents that are prescribed on a scheduled basis (i.e. 48-72 hour antibiotic “time-out”)

61 39 67 33

3. Facility has written policy to require an indication for use on all prescribed antimicrobial orders. 35 65 58 42

4. Facility has ID syndrome specific guidelines (urinary tract infections, community acquired pneumonia, etc.) set in place based on local antimicrobial susceptibility patterns.

17 83 17 83

5. Facility conducts and documents prospective audits of specified antimicrobials of interest with feedback provided to the prescribers. 43 57 50 50

6. Facility uses an alert system to identify unnecessary duplicate antimicrobial therapy. 13 87 42 58

7. Facility uses an alert system to identify met eligibility criteria for IV to PO conversion of antimicrobial therapy administration. 13 87 58 42


TrackingGeneral Hospital (n=23) Critical Access (n=12)

No (%) Yes (%) No (%) Yes (%)3. Facility systematically tracks antimicrobial usage at a facility-wide level 13 87 25 75

a. At a facility unit/ward level 61 35 50 42b. At a facility team level 78 17 92 0c. At a facility individual prescriber level 83 13 67 17

4. Facility systematically tracks antimicrobial usage based on spectrum on activity (i.e. broad-spectrum vs narrow-spectrum) 35 65 67 33

5. Facility systematically tracks adverse drug reactions as related to antimicrobial agents 26 74 8 92

10. Facility systematically tracks positive microbiology culture growth and susceptibility data at a facility-wide level. 4 96 8 92

a. At a facility unit/ward level 39 61 92 8b. At a specimen (i.e. blood, urine, respiratory, CSF, etc.) level 35 65 67 33


ReportingGeneral Hospital (n=23) Critical Access (n=12)

No (%) Yes (%) No (%) Yes (%)1. Facility benchmarks antimicrobial usage data to compare with peer/network facilities 35 65 75 25

2. Facility regularly provides opportunities to share antimicrobial usage data at a facility-wide levels including administration and medical/laboratory staff (Grand Rounds, etc.)

17 83 25 75

a. At a facility unit/ward level 74 17 67 25b. At a facility individual prescriber level 74 22 67 253. Facility provides antimicrobial usage data in a convenient format for quick access/reference by administration, physicians, etc.

35 65 33 57

a. If yes, data is regularly updated 9 65 0 675. Facility regularly provides positive microbiology culture growth and susceptibility data (i.e. antibiogram) at a facility-wide level

0 100 8 92

a. At a facility unit/ward level 43 57 83 176. Facility provides positive microbiology culture growth and susceptibility data in a convenient format for quick access/reference.

0 100 17 83

a. If yes, data is regularly updated 0 100 0 83


EducationGeneral Hospital (n=23) Critical Access (n=12)No (%) Yes (%) No (%) Yes (%)

1. Facility provides regular continuing education opportunities for medical staff specifically regarding antimicrobial stewardship (including reviews of microbial resistance mechanisms, antimicrobial spectrums, etc.)

57 43 50 50

2. Facility assesses knowledge post antimicrobial stewardship education of medical staff to verify understanding.

78 22 83 17

3. Facility supports opportunities to attend meetings/conferences that include antimicrobial stewardship as a topic.

30 70 25 75

6. Facility acknowledges and actively promotes/participates in the United States Antibiotic Awareness Week (formerly the CDC’s Get Smart About Antibiotics week)

39 61 42 58

8. Facility provides antimicrobial stewardship specific education at new hire/resident orientation 30 70 58 42

9. Facility provides goals for achievement of specific antimicrobial stewardship education (checklists, etc.) 70 30 83 17

10. Facility incentivizes staff to obtain antimicrobial stewardship specific training (special recognition, etc.) 83 17 83 17



Gary Wheeler, MD, MPS

Naveen Patil, MD, MHS

Dirk Haselow, MD, PhD, MS

Kelley Garner, MPH MLS(ASCP)CM

Pam Higdem, BSN, RN, CIC

Rohan Chakravorty, MPH

Trent Gulley, MPH

Rachel Mahurin

Non-ADH Contract Staff

Corey Lance, PharmD

Questions?

Program Staff Acknowledgements

2019 HAI Stead Scholars

Jordan Mallard

Ruby Trotter

Documents

Update on the Infection Control and Antimicrobial ... · efforts to improve antibiotic use (antibiotic stewardship). 27% 73% 15% 85% B. The facility has identified individuals accountable