Continuing a long-term trend, F880 (Infection Prevention and Control) ranks as the No. 1 deficiency handed out by surveyors since January 2019, most commonly at a scope and severity of D (54 percent), E (30.9 percent), or F (3.3 percent), according to the recent AADNS article, “How to Avoid Citations for the Top Two Most-Cited Deficiencies.”
A key problem in many nursing homes is inadequate infection surveillance. The written standards, policies, and procedures for an infection prevention and control program (IPCP) must include “a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility,” according to §483.80(a)(2)(i) of the Code of Federal Regulations.
Historically, long-term care surveillance has been rudimentary, points out Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and faculty member at the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA. “For example, providers would collect data in a binder on culture results and related lab results, antibiotic use, and residents on isolation; count those up; and call it surveillance.”
However, infection surveillance is much more complex than that, and the Centers for Medicare & Medicaid Services (CMS) wants providers to have a more formalized surveillance program, says Burdsall. “You have to understand the epidemiological concepts of incidence and prevalence rates; how to calculate infection rates; and how to feed that information back in a feedback loop to the frontline providers—the people who can actually do something about what is going on with infection data.”
It’s also important to understand that there are different types of surveillance, says Burdsall. “There is outcome surveillance, which includes monitoring for infections, antibiotic use, and susceptibility. However, there is also process surveillance, which includes environmental cleaning and disinfectant surveillance and hand hygiene surveillance.”
Note: The surveyor guidance at F880 in the December 2017 version of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual has several critical sections that address infection surveillance, including: Surveillance; System of Surveillance: Data Analysis, Documentation and Reporting; and Recognizing, Containing and Reporting Communicable Disease Outbreaks. In addition, there is an infection surveillance module in the CMS-approved Nursing Home Infection Preventionist Training Course.
With flu season here, many providers start to think about infection surveillance, notes Burdsall. “However, you need a working infection surveillance program in place 365 days a year.”
With the support of the director of nursing services (DNS), the infection preventionist can implement the following steps to develop an effective infection surveillance program:
Assess your overall IPCP
Infection preventionists must be able to allot dedicated time to perform a baseline assessment of the facility’s IPCP, says Evelyn Cook, RN, CIC, associate director for the Statewide Program for Infection Control and Epidemiology (SPICE) at the University of North Carolina at Chapel Hill.
“First conduct a checklist assessment of what written policies and procedures you have in place,” she says. “Then do a walkthrough, including environmental rounds, to assess whether your policies and procedures are being implemented: Do you have this component in place? Do you have that one in place?” Note: The Centers for Disease Control and Prevention (CDC) offers the detailed Infection Prevention and Control Assessment Tool for Long-term Care Facilities.
Doing this baseline assessment gives the infection preventionist the information necessary to do a risk assessment and help the facility establish infection prevention and control goals, including the goals of the surveillance program, says Cook. “You can’t tackle everything at once. You have to do that initial assessment so that you know what your top priorities are. It’s also a good idea to limit your goals to maybe two or three initially, as well as to make them measurable so you can determine whether you are successful.” Note: The CDC offers this IPC Risk Assessment Spreadsheet, which is adapted from a SPICE tool, to help providers do this prioritization.
Choose standardized surveillance definitions
Effective surveillance requires using standardized definitions to define what an infection is—as evidenced by CMS’s requirement under F880 that a facility’s surveillance system must include the use of nationally recognized surveillance criteria, says Cook. “It is critical to identify a set of standardized definitions to use, but some providers still struggle with that. For example, facilities may use definitions driven by MDS coding and its supporting documentation, antibiotic starts, or physician diagnoses to determine when to call an infection an infection. However, many of those types of definitions are highly subjective.”
Without standardized definitions, providers will never be able to fully understand their own internal infection rates—let alone benchmark those rates against other organizations, says Cook. “For example, if you use one definition for urinary tract infections (UTI) today and another tomorrow, you can’t compare the two. It’s like comparing apples and oranges. However, using a set of standardized criteria that you apply to every situation allows you to say, ‘This resident was looked at the same way that this other resident was looked at.’”
Until all providers use standardized definitions, it will remain difficult to compare and to really identify where the greatest need is related to infections in long-term care, adds Cook. “Not using standardized definitions is one of the reasons we have limited published data related to infection rates in long-term care facilities.”
The bottom line is: Providers need to have a written surveillance program, identifying what infections will be monitored and what definitions will be used, says Cook. Note: Review SPICE’s IPCP policy template, which includes a surveillance program policy.
Two primary sets of surveillance definitions are available for nursing homes to use, according to both Cook and Burdsall:
CMS allows providers to choose which standardized definitions they use, notes Cook. “At SPICE, we recommend that providers use the McGeer criteria unless they are reporting to NHSN. But whatever definitions you choose, it’s important for leadership, including the quality assessment and assurance/quality assurance and performance improvement (QAA/QAPI) committee, to come to a consensus. Everyone may not agree with a particular definition. For example, the medical director may not agree with a definition, or the DNS may not agree with a definition. However, you need to come to a consensus so that you can then educate your physicians and other stakeholders about those definitions.”
Understand what the Loeb criteria actually are for
Some providers use what’s known as the Loeb criteria as surveillance definitions, points out Burdsall. “However, the Loeb criteria are not population-based surveillance definitions the way the McGeer criteria are. The McGeer definitions are standardized definitions that apply to everyone. If a resident doesn’t meet the definitions, they aren’t counted. This allows you to, for example, compare UTI to UTI to UTI month to month to month.”
In contrast, the Loeb criteria are essentially the minimum number of symptoms that a resident needs to start an antibiotic, explains Burdsall. “So instead of being population-based surveillance definitions, the Loeb criteria are person-centered criteria for starting antibiotics, which is very important but a very different thing.” Note: Similarly, the Agency for Healthcare Research and Quality offers a Minimum Criteria for Antibiotics tool as part of its toolkit, Determine Whether It Is Necessary To Treat a Potential Infection With Antibiotics.
The Loeb criteria were never really designed for surveillance, agrees Cook. “They are supposed to be a type of ‘cheat sheet’ to assist physicians in determining when antibiotic therapy should be initiated.”
Note: It’s worth pointing out that the surveyor guidance in Appendix PP separates the use of these criteria, citing the NHSN definitions and the McGeer criteria as examples of nationally recognized surveillance criteria under F880, while citing the Loeb criteria as an example of the standardized tools and criteria providers must use to assess residents for any infection as part of their antibiotic stewardship program under F881 (Antibiotic Stewardship Program).
Be consistent applying surveillance definitions
Once providers have decided what surveillance definitions to use, it’s important to adhere to and consistently apply those definitions, says Cook. “Leadership also should empower the infection preventionist to enforce the surveillance definitions and make sure the surveillance program works.”
That doesn’t mean a physician can’t disagree from a clinical perspective, points out Cook. “Sometimes a doctor will say, ‘This isn’t an infection.’ In that situation, the infection preventionist needs to reply, ‘You are probably right from a clinical perspective. However, it meets our surveillance definition, so I am going to include it in my infection rate reports. Sometimes an issue that may not be an infection meets the criteria, but sometimes there will be a true infection that doesn’t meet my criteria. It will even out.’ You have to consistently apply those definitions.”
Surveillance definitions are neither diagnoses nor practice guidelines, adds Burdsall. “Sometimes providers will tell doctors to discontinue antibiotics based on surveillance definitions. However, that is not at all what surveillance definitions are meant for. This is where the Loeb criteria come in, providing the prescriber with an appropriate evaluation that helps them to make an informed, person-centered treatment decision on whether the resident needs an antibiotic.”
Choose a strong infection surveillance tool
In addition to requiring providers to use nationally recognized surveillance criteria, CMS requires that a facility’s surveillance system include a data collection tool, says Burdsall. “Providers can choose what tool they want to use, but I have been suggesting the free Infection and Antibiotic Use Tracking Tool that is part of the Minnesota Department of Public Health’s Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities, which is an active site that Minnesota updates consistently. This tool is probably the best surveillance module I have found, and it’s a superb starting point for anyone who has been cited for infection surveillance under F880,” she explains.
Note: The tool consists of an Excel-based tool and PDF instructions. Minnesota also offers a February 2019 one-hour WebEx presentation on how to use the tool.
Essentially, the infection preventionist needs to obtain from the business office the number of resident days per month, says Burdsall. “This information allows you to calculate both your infection rates and your rates of antibiotic therapy use. There is a summary page where you can look month by month at your entire year, and there are monthly tracking sheets where you enter the data you collect for infection surveillance and antibiotic tracking.”
The data to be collected is fairly extensive, acknowledges Burdsall. “It’s asking a lot, but it will really help you in the long run if, for example, you receive a call from local health department officials that they have noticed an outbreak based in your facility. This data is everything you need not only to start doing appropriate infection surveillance but also to track antibiotics.”
The tool covers the following:
Resident information, such as unit name and room number(s);
Classification information, such as the infection type (using a drop-down menu) and whether the infection meets the surveillance definition;
History, such as symptoms, device information, and other risk factors;
Diagnostics (microbiology, other labs, radiology);
Antimicrobial starts; and
Other information, such as whether transmission-based precautions were required.
All of this data needs to be collected, but most infection preventionists probably don’t have the time to have sole responsibility for data collection, says Burdsall. “Look for opportunities to obtain data from other sources. For example, your pharmacist may be able to add in some of this information.”
Note: The Minnesota tool has a surveillance definition worksheet based on the McGeer criteria for the infection surveillance section of the tool, while using a Loeb criteria tool for the antibiotic use section of the tool.
Collect data—and offer feedback—in real time
“Long-term care infection surveillance is often retrospective, but retrospective data collection and review are not really helpful,” says Burdsall. “You don’t want to collect data for data’s sake.”
Providers should collect data in real time in order to look at trends and patterns and determine whether infection prevention efforts are not preventing infections, says Burdsall. “You need to know day to day who has symptoms, who is being treated, who has positive lab reports, and whether those positive lab reports mean anything,” she explains.
“Then clusters, outbreaks, or inappropriate antimicrobial use ideally need to be dealt with in real time as well so that, if you see a problem, you can address it with whichever interdisciplinary team members can do something about it, whether that’s the staff nurses, the certified nursing assistants, or the prescribers,” says Burdsall. “The goal is to have a real-time, prospective infection surveillance program with an effective feedback loop.”
“Infection preventionists should have a plan in place for monitoring not only the outcome—the infection—but also for monitoring the processes that led to the outcome,” adds Cook. “For example, that might be monitoring hand hygiene, use of personal protective equipment (PPE), or care of Foley catheters. To put an effective plan in place to address your outcomes, you have to measure processes to determine their effectiveness and whether additional interventions should be considered.”
Note: Want help improving the feedback loop? TeamSTEPPS in LTC: Communication Strategies to Promote Quality and Safety is a module in the QIO Program’s Nursing Home Training Sessions.
Beef up your knowledge of flu-like illnesses
During influenza season, other respiratory viruses that cause influenza-like symptoms often circulate, says Burdsall. “Staff can’t assume that flu-like symptoms mean a resident has influenza. For example, a resident may have human metapneumovirus, respiratory syncytial virus (RSV), or another respiratory virus that requires a different treatment or a different type of isolation than influenza. For example, antiviral medication used to treat influenza won’t help a resident with RSV.”
To educate staff about respiratory illnesses, it can be helpful to partner with a local hospital infection preventionist, the local health department, an infectious disease physician, or even an infection-certified pharmacist, suggests Burdsall.