Clinical Corner

Antibiotics now give us the ability to treat common types of infections that were once lethal; however, they can be detrimental when used inappropriately. According to the Centers for Disease Control and Prevention (CDC), 70% of nursing center residents receive one or more courses of systemic antibiotics per year and 40%-75% of antibiotics prescribed may be unnecessary or inappropriate. Some of the risks associated with inappropriate use of antibiotics include increased morbidity and mortality, increased risk of hospitalization, increased risk of C. difficile infection, and increased treatment costs. Overuse can also lead to antibiotic resistant organisms, for which there are limited treatment options.

In response, the CDC began urging health care facilities to implement an antibiotic stewardship program (ASP) with the goal of optimizing the treatment of infections while reducing the adverse events associated with antibiotic use. Both the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (TJC) have also recognized the importance of antibiotic stewardship and now require implementation of an ASP in accordance with the CDC core elements of antibiotic stewardship as of November 2017 for CMS and January 2018 for TJC. There are seven core elements of an ASP according to the CDC publication, The Core Elements of Antibiotic Stewardship for Nursing Homes:

• Facility leadership commitment to safe and appropriate antibiotic use;
• Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship;
• Accessing pharmacists and others with experience or training in antibiotic stewardship;
• Implementing policies or practices to improve antibiotic use;
• Tracking measures of antibiotic use in the facility (i.e., one process and one outcome measure);
• Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; and
• Educating staff and residents about antibiotic stewardship.

To assist nursing centers with starting an ASP in accordance with the CDC core elements, the Agency for Healthcare Research and Quality (AHRQ) has developed a detailed toolkit, Start an Antimicrobial Stewardship Program, which emphasizes four steps to implementing an ASP.

Identify champions and gather a team

Establish a multidisciplinary team consisting of staff with varying responsibilities such as charge nurses, the director or assistant director of nursing, the medical director, the infection preventionist, and an information technology staff member (if an electronic medical record is used). The team may also include consulting pharmacists, prescribing clinicians, and/or resident or family representatives. Two champions should be appointed to ensure program leadership through times of staff turnover, to promote the importance of the program, and to be accountable for outcomes. Champions should be responsible for developing agendas and policies, and leading trainings. Other team members can be assigned responsibilities such as assisting with developing training, the implementation of new tools, abstracting data for monitoring, and reporting data.

 Conduct a readiness assessment

The purpose of the readiness assessment is to determine what resources the program will need and how ready the organization is to take on new interventions. It takes into account each nursing center’s unique characteristics and can help to determine which stewardship goals are reasonable. The assessment also helps to select and prioritize specific interventions. A step-wise implementation is encouraged in which only one or two interventions are rolled out at a time.

 Plan for intervention

Based on the readiness assessment, the team can develop a plan including a timeline, responsibilities and a schedule for team meetings. When planning the timeline for the project, consider time for training staff, developing policies, and informing all parties involved with the process. Developing new policies and procedures that support the selected interventions will help hardwire and sustain the ASP. Meetings leading up to implementation should include a review of the purpose of the program, discussion of the tools that will be implemented, how the workflow will be adjusted to incorporate new tools, and a projected budget. Also discuss what materials need to be developed to support implementation as well as methods to communicate information about the intervention to staff, prescribing clinicians, and other facilities as necessary.

Introduce new policies and procedures to staff

New policies and procedures should answer the questions of who, what, when, where, why, and how. Prior to implementation, policies and procedures should be shared with staff via clear and easy-to-understand methods. A statement of the organization’s commitment to quality of care as well as the purpose, scope and goals of the program should be expressed in the policy. Additionally, details regarding when the program will start and who will be involved should be included. Procedures should include the goals of specific interventions, what tools will be used to support the intervention, how the intervention will be implemented, and the staff responsible for the intervention. Depending on the scope of the new procedures, staff training may also be necessary.

As with any successful QAPI project, there should be a plan for monitoring and sustainment, which will also be addressed by the ASP team. The team should discuss what to monitor, who will collect the necessary data, how often the data will be collected, and the data source. Both process measures and outcome measures should be collected to adequately demonstrate progress of the ASP. To ensure that the ASP will be sustained, ongoing evaluation and reassessment based on feedback from staff as well as process and outcome measures is vital. By using quality improvement tools such as the plan-do-study-act (PDSA) model, continue to adapt and modify the program as necessary. Most importantly, celebrate successes as they occur to keep staff engaged.

1. The Core Elements of Antibiotic Stewardship for Nursing Homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2015.
2. Implement, Monitor, and Sustain an Antimicrobial Stewardship Program. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD.

Isolation is a significant aspect of a nursing center’s infection prevention program. Its purpose is to avoid the spread of nosocomial or in-house developed infection. The Centers for Disease and Prevention (CDC) guidance recommends using standard precautions for the care of all, regardless of the presence of illness or infection status.  Standard precautions extend beyond protecting health care workers from exposure to blood borne pathogens and include body substances that may contain potentially infectious microorganisms. This applies to blood, all body fluids, secretions and excretions except sweat, regardless of whether or not they contain visible blood, non-intact skin and mucous membranes.

In addition to standard precautions, it is prudent for centers to implement transmission-based precautions. The CDC guides us that transmission-based precautions are in addition to standard-based precautions. They should be used as proactive or preventative measures that need to be implemented when there is suspicion of colonization and or infection due to a highly infectious or epidemiologically significant organism in order to interrupt transmission to others. There are three types of transmission-based precautions:

• Contact,
• Droplet, and
• Airborne isolation.

Contact isolation includes the use of gowns and gloves when in the immediate patient care environment. Droplet precautions require the use of a mask when within three-to-six feet of the patient. Airborne isolation requires the use of an N95 mask in addition to the patient being placed in a negative pressure room. At times, more than one type of isolation may be necessary in order to interrupt transmission of infection. For example, some respiratory illnesses, such as those due to multi-drug resistant organism or adenovirus, require both contact and droplet precautions. Disseminated shingles or someone who is immunocompromised is another example that requires two types of isolation, airborne and contact.

Isolation precautions can be challenging in the long term care environment, especially when it comes to determining when isolation precautions can be discontinued. The Healthcare Infection Control Practices Advisory Committee (HICPAC) 2007

Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings is the go-to resource for recommendations on the type and duration of isolation required for infections; however, there are times when the guidelines do call for evaluation of the patient and environment in order to make a decision on discontinuing isolation. This scenario is often encountered when a resident has an infection due to a multi-drug resistant organism (MDRO) such as MRSA, ESBL or MDR-Pseudomonas. To determine when to discontinue isolation precautions, consider:

• Is the resident symptomatic?
• Has the resident been treated for their infection?
• Does the resident have any draining wounds or uncontained body fluids?
• Are there currently other residents with this type of infection, making it more challenging to prevent transmission to others?
• Does the resident have the ability to maintain good hand hygiene or can staff ensure the resident performs hand hygiene prior to leaving their room?

An important note: residents who are colonized or have an infection due to an MDRO must be asymptomatic, have all body fluids contained and have hand hygiene performed in order to discontinue isolation.

We encourage you to use the best support and science available to not only protect your residents/patients, staff and visitors, but to also reduce your organizational risk.  Promising care practices include inclusion of CDC and/or APIC guidelines for evidence-based guidance.

The Centers for Medicare and Medicaid Services (CMS) defines person-centered care as a process that is normally directed by the resident, family or other intended to identify strengths, capacities, preferences, and needs. Wikipedia defines person-centered planning (PCP) as a set of approaches designed to assist someone to plan their life and supports. It is used most often as a life planning model to enable individuals with disabilities or otherwise requiring support to increase their personal self-determination and improve their own independence.

In long term care, specifically in the nursing care center, we care for a complex group of individuals. Acuity has been steadily on the rise in individuals with medical, behavioral, psycho-social and physical needs based on the gaps that their lack of wellness creates.  In my experience, most residents who were able to discuss their needs, wants and hopes stated that, when asked about their acknowledged wishes and goals, they hoped to improve in their overall condition and wellness so they could increase their independence, continue various hobbies, attend their church or synagogue and return to or stay in their own homes. Typically, the goals were more personal rather than clinical in nature.

The development of person-centered care plans not only benefit the resident and the family/friends, they also support the staff.

Person-centered care benefits everyone

Person-centered care benefits residents by adding autonomy and increased ability to self-direct care and services. Resident choice fosters engagement and improves quality of life. Residents live in an environment of trust and respect. Residents are in a close relationship with staff who are attuned to their changes and can respond appropriately. Residents continue to live in a way that is meaningful to them as individuals.

Center staff become more comfortable caring for the people they know reflecting permanent team assignments. This makes staff more comfortable caring for people they know. You will see relationships between residents and staff and families and staff flourish.

Person-centered care benefits nursing centers

Quality outcomes for residents improve due to the ability of staff to identify and respond appropriately to changes in a resident’s conditions and/or wishes. Nursing centers gain referrals from people who have good experiences and recommend the nursing centers to others as a place for care. Staff retention is enhanced based on the relationships shared between the caregiver and resident.

Robin A. Bleier is President of RB Health Partners, Inc., a clinical risk, Medicare and operations firm that consults with FHCA on quality affairs. For more information, call Robin at (727) 744-2021 or email her at [email protected].