Overcoming Message Resistance


>>Good afternoon. I’m Commander Ibad Khan, and I’m
representing the Clinician Outreach and Communication Outreach, COCA, with
the Emergency Risk Communication Branch of the Centers for Disease
Control and Prevention. I would like to welcome you to today’s
COCA call, Preventing the Spread of Novel or Targeted Multidrug-resistant
Organisms, MDROs, in Nursing Homes through
Enhanced Barrier Precautions. You may participate in today’s presentation
via webinar, or you may download the slides if you’re unable to access the webinar. The PowerPoint slides and
the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Again, that web address is
emergency.cdc.gov/coca. Free continuing education
is offered for this webinar. Instructions on how to earn continuing education
will be provided at the end of the call. In compliance with continuing education
requirements, CDC, our planners, our presenters, and their spouses partners wish to disclose that
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to ensure there is bias. Content will not include any discussion
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for this continuing education activity. After the presentation, there
will be a Q and A session. You may submit questions at any time during
the presentation through the Zoom webinar by clicking the Q and A button at the bottom
of your screen and then type in your question. Please do not ask a question
using the chat button. Questions regarding the webinar should
be entered using only the Q and A button. For those who have media questions, please
contact CDC media relations at (404) 639-3286 or send an email to [email protected] If you are a patient, please refer your
questions to your healthcare provider. At the conclusion of today’s session, participants will be able
to accomplish the following. One, describe the burden of
multidrug-resistant organsims, MDROs. Two, describe challenges to prevent
MDRO transmission in nursing homes. Three, define standard precautions, enhance
barrier precautions, and contact precautions. Four, identify which residents at activities
meet criteria for enhanced barrier precautions. And, five, discuss best practices for
implementing enhanced barrier precautions. Now, I would like to welcome our
first presenter, Dr. Nimalie Stone. Dr. Stone is the team lead for long term care within CDC’s division of
healthcare quality promotion. He’s a board certified infectious
disease physician with over ten years experience developing
surveillance epidemiologic research and quality improvement projects
to track and prevent infections and antibiotic resistant pathogens in
post acute and long term care settings. In her role at CDC, Dr. Stone overseas the
development of guidance, educational resources, and implementation tools to
support infection prevention and antibiotic stewardship
activities in nursing homes. I would also like to extend a warm welcome to
our second presenter, Dr. Kara Jacobs-Slifka. Dr. Jacobs is a medical officer
with the long term care team within CDC’s division of
healthcare quality promotion. She is a board certified infectious
disease physician who has a research and clinical background in managing infections
and antibiotic resistant pathogens as well as investigating domestic and
international outbreaks of infectious disease and performing healthcare
associated infection surveillance. In her role at CDC, Dr. Jacobs continues
to work to contain and prevent the spread of antibiotic resistant and emerging pathogens
in the post acute and long term care settings through the development of guidance and
educational resources and the support of state and local health department. I would now like to welcome our
first presenter, Dr. Nimalie Stone. Dr. Stone, please proceed.>>Thank you. Good afternoon, and welcome to
all of you who have joined us. As you’ve heard, during this call, we’re
going to talk about the growing problem of multidrug-resistant organisms
in nursing homes and focus on the challenges stopping the
spread of novel and targeted MDROs that have been identified during public
health responses in this setting. We’ll discuss the different levels of
precautions used to disrupt MDRO transmission and introduce a new approach for nursing
homes called enhanced barrier precautions. The issue of antibiotic resistance
in healthcare is not a new challenge. The CDC antibiotic resistance stress report
released in 2013 has been raising awareness to the significant burden
of resistant organisms, causing more than two million infections and
over 20,000 deaths in hospitals each year. In your own clinical experience, you’ve
probably observed that infections from these pathogens are often more
severe, difficult, and costly to treat. Since this report, we have only continued to
identify novel and emerging resistant organisms to the expansion of our laboratory and
public health capacity to detect them. On this slide are just a few of the pathogens
highlighted in the antibiotic resistance report. Methicillin-resistant staphylococcus aureus or
MRSA is frequently encountered in nursing homes as a cause of infection and
a colonizing organism. Similarly, the extended spectrum
beta-lactamase producing Enterobacteriaceae or ESBLs drive cephalosporin resistance in
many of the common gram negative bacteria such as E. coli Escherichia that
can be seen in urinary tracts. Carbapenem resistance in Enterobacteriaceae
had been left commonly identified in centers, however we are starting to find this
resistance emerging in the nursing home settings as well as other healthcare centers. A specific type of carbapenem resistance
of particular concern has been the rise of carbapenemase producing organisms. These bugs produce enzymes that can destroy
the carbapenems and tend to carry resistance to many other classes of antibiotics. The genes causing this resistance travel
on mobile genetic elements called plasmids that can easily spread to other bacteria. When they cause invasive infections, the
mortality rates can be quite high, up to 50%, due to the limited antibiotic
treatment options available. And, we are detecting carbapenemase
producing organisms in healthcare facilities
across the United States. Listed on this slide for
your information are examples of the different carbapenemase producing
genes that result in high level resistance. CDC tracks carbapenemase
by the genetic mechanism. These genes have been reported in a wide
variety of Enterobacteriaceae as well as in pseudomonas aeruginosa
and Acinetobacter baumannii. While commercial laboratories providing services to nursing homes will be reporting
carbapenem resistance or nonsusceptibility, they may not have the ability to determine
whether carbapenemase is the underlying cause of that resistance. And, that is where public health
laboratories can offer additional testing to detect those carbapenemases
and support facilities when they may be seeing new carbapenem
resistance occur in their patients. Another important public health
threat to mention is candida auris. This emerging fungal pathogen has been getting
a lot of attention because of its potential to develop drug resistance, its ability to cause
serious invasive infections, and the rapid ways that this yeast has been shown to
spread in healthcare facilities. We will look at a facility’s experience
with candida auris during an outbreak in a few minutes, but first,
let’s look at what we know about the current state of
MDROs in nursing homes. This recently published experience
involving 18 nursing homes shows a snapshot of MDRO prevalence on a single day. This group conducted surveillance
grading by culturing different body sites from a random sample of 50
residents across skilled, long stay, and ventilator units in each facility. In the 14 centers with skilled and
long stay units, the median prevalence of any MDRO being detected was 58%. However, in the four nursing homes
with specialized ventilator care units, the median prevalence rose to nearly 80%. The most commonly identified MDRO was MRSA,
ranging in colonization prevalence from 25% to upwards of 60% colonizing residents tested
in a facility followed by ESBLs at around 25%. While CR recolonization was rare, less than 1% in the 14 nursing homes providing only skilled
care, the median CRE prevalence was 10% in the facilities with ventilator units. So, it asks the question what is driving
this high burden of MDROs in nursing homes. As hospitals are becoming the main source of
admissions, there’s been a steady increase in the acuity and medical complexity
of care delivered in this setting. Residents today have multiple risk factors
such as indwelling medical devices, wound care, recent antibiotic use, and hospitalizations
coupled with frailty, comorbidity, and functional dependence, all of
which have been shown to be associated with MDRO colonization or
the risk for acquisition. In addition, the frequent
patient transfers among acute care and post acute care facilities specifically
is long term acute care hospitals and nursing homes has been
demonstrated in several studies to facilitate the spread
of MDROs within a region. As shown in this figure which tracks
CRE cases moving throughout a network of interconnected facilities. The amplification of resistant
organisms has been greatest in centers that serve a high acuity population with
long lengths of stay in an environment with limited staffing or
challenges with implementation with infection prevention practices. If we go back to the findings from the
MDRO prevalence project for a moment, we see another challenge revealed. Once the team had identified the
colonized residents in each facility, they went back to review medical
records to determine how many of those individuals had already been known
to be colonized within MDRO by the facility. Overall, in the traditional skill
centers, only a median of 17% of the MDRO colonized individuals had
any documentation of the organisms that they were carrying, and
even in the centers caring for a higher risk ventilator
dependent population, the median percent documented
with an MDRO was still only 20%. So, the actual prevalence of MDRO colonization
is anywhere from three to four times higher than what is documented in the records. So, this burden is not only high but
goes unrecognized in a lot of places. And, there are many reasons why nursing
homes might be unaware of the true prevalence of MDRO colonization in the
residents that they care for. Most centers rely on clinical cultures
to reveal the presence of pathogens and it’s illustrated by this iceberg. Those infections only represent an
exceedingly small portion of carriers. Most facilities do not have the capacity
to perform surveillance screening to detect that asymptomatic carrier
reservoir despite the fact that these individuals can
contribute significantly to the spread of MDROs within a facility. And, it’s demonstrated by the
findings of that medical record review. Information about MDRO history or risk factors for MDRO colonization are often inadequately
communicated during transitions of care. Given the difficulties with managing
MDROs, you can see why the novel organisms with their capacity to share resistant elements,
avoid detection, and spread readily within and across facilities pose such a threat. And, it’s these characteristics
that are the reason why CDC and public health programs are
targeting them for containment responses. The CDC containment strategy was launched
in 2017, and it’s a systematic approach led by public health to slow the spread
of emerging antibiotic resistance. Containment responses have three
main components, detection, which triggers a public health investigation
and response to the identification of even a single case, infection control
including on site assessments conducted by the health department for any facility that
is cared for, colonized, or infected patients, and contact screening which is provided through
the antibiotic resistance laboratory network and offered to the healthcare contacts
of any colonized cases such as roommates or other patients or residents on a unit or
floor where those patients received care. And, this is done to detect the silent
spread that might have occurred. When transmission is identified,
ongoing infection control assessments and screenings continue to occur until that transmission has been
shown to stop or substantially slow. In the first two years of
the AR containment strategy, we reviewed over 100 CDC
supported responses and found that over 60% involved post
acute care facilities such as long term acute care hospitals, nursing
homes, and in patient rehabilitation facilities. Seventy percent of those post acute
care facilities provided some type of specialized ventilatory support, and while
ventilator services are relatively infrequent in nursing homes, available in less than 5%
of the 15,600 centers in the United States, at least if not more than a quarter of the air containment responses have
involved nursing homes with ventilator units, really highlighting the increased vulnerability
of patients needing this level of care. To illustrate, let’s look at how
a candida auris outbreak unfolded in a ventilator unit of a nursing home. This unit had 30 rooms with a mix of double,
triple, and even a few four person rooms. The response began in March of 2017 with the
screening of 65 residents for candida auris in response to identifying a known
case that had come into the facility. And, as you can see by this floor map,
initially, no additional cases were detected. But, by about ten months later, as a result of
both importation and transmission on the unit, the prevalence of candida auris
had reached just over 40%. To add an additional level of complexity
to the situation, it was found that 2/3 of the candida auris colonized
residents were co-colonized with one or more carbapenemase producing
organisms or CPOs. The array of different combinations of resistant
pathogens created additional challenges with efforts to house roommates together
or cohort individuals on the unit in a way that could slow the spread. As shown on this slide, roughly 18 months from
the detection of that first candida auris case, the prevalence now on this unit had increased
to 70% along with the 60% CPO prevalence. Consistently, the same challenges
and basic infection prevention and control practices had been described across numerous nursing homes
involved in AR containment responses. These include gaps in hand hygiene
adherence often due to a lack of access to alcohol based hand rub
dispensers or a lack of knowledge that alcohol based hand rub
dispensers is preferred for most hand hygiene opportunities
at the bedside. Minimal use of contact precautions and limited
access to personal protective equipment, like gowns, challenges with cleaning and
disinfection of both environmental surfaces and shared resident care equipment and for
communication during interfacility transfers. And, unfortunately, delays and problems
addressing these gaps can result in the amplification of resisted
pathogens within this population. The containment experience really
demonstrates that preventing the spread of MDROs requires attention to
a whole portfolio of practices. And, as I hand over this presentation to
my colleague, Dr. Jacobs to dive deeper into the role of personal protective equipment
and precautions, this slide is a reminder that gown and glove use is just one of
many prevention strategies that are needed to successfully halt transmission. Dr. Jacobs.>>Thank you, Dr. Stone. Focusing on personal protective equipment or PPE and our previously existing precautions
one common observation that we have made in nursing homes across the
country has been that standard and transmission based precautions
are not consistently applied. And, inadequate access to PPE
can directly contribute to this. I want you to think about standard precautions and transmission based precautions
as being on the spectrum. With standard precautions requiring the decision
is made before providing care regarding the necessary PPE to use for any potential exposure. While transmission based precautions, on the
other side, dictate the use of specific PPE and other restrictions based on
a known or suspected pathogen. Standard precautions is a group of infection
prevention activities that applies to the care of all patients in all healthcare
settings, regardless of suspected or confirmed infection or colonization status. And, they’re based on the principle
that all blood, body fluids, secretions, and excretions may contain
transmissible infectious agents. Standard precautions include PPE use
selected based on anticipated exposures, hand hygiene which is the primary means of
preventing the spread of infection pathogens, injection, and medication safety,
respiratory hygiene, and cough etiquette which may involve the use of PPE such as
masks, environmental cleaning and disinfection and reprocessing of reusable medical equipment. Transmission based precautions are used when standard precautions alone
does not interrupt the transmission of an infectious pathogen. The PPE and precautions are based
on the method of transmission of a known or suspected pathogen. Contact precautions is used to prevent the
spread of pathogens directly from person to person or indirectly through
an intermediate object or person. Droplet precautions prevent the spread of large
respiratory droplets over short distances, and airborne precautions are designed
to prevent the spread of small particles that may remain infectious
over time and distance. CDC has also recently developed this sample
signage which is available on our website. Contact precautions is the type of
existing transmission based precaution that has been used for MDROs. However, as I mentioned earlier, contact
precautions has been applied inconsistently for a variety of reasons across nursing homes. As a part of contact precautions, hand hygiene
should be performed and gown and glove use, gown and gloves should be donned
before room entry and then removed with hand hygiene performed before room
exit or providing care to another resident. The resident should have dedicated equipment
and, ideally, the resident has a private room and is restricted to the room and does
not participate in group activities. Applying contact precautions, as I’ve just
described in nursing homes can be very complex and is made even more complicated and
confusing for MDROs based on how we’ve defined and described transmission based precautions. So, this language is pulled from the
current CMS state operations manual or interpretative guidance for long term care
which has then been taken from CDC guidelines and describes that transmission
based precautions must be used when a resident develops signs and
symptoms of a transmissible infection. But, as we have described, individuals
colonized with MDROs are asymptomatic and do not have the signs and
symptoms seen during infection. The interpretative guidance, then, goes on to
advise that facilities must identify the type and duration of transmission based precautions and that those precautions should be the least
restrictive for the least amount of time. But, the duration of MDRO colonization
in nursing home residents often lasts for many months and sometimes longer. The language then goes on to further specify
that when a resident is no longer at risk for transmitting infections, transmission
based precautions should be removed. But, we know that residents remain
at risk for transmitting MDROs even if they are not actively infected. So, focusing only on residents with active
infection fails to address the continued risk of transmission from residents with MDRO
colonization which can persist for long periods of time and result in the
silent spread of MDROs. There’s also a very real and a very
important balance that we need to find between maintaining resident safety, and by
resident safety, I’m talking specifically about preventing the spread of infectious
pathogens, including MDROs, and resident quality of life, including respecting the homelike
environment, the importance of socialization and psychosocial wellbeing while
maintaining the stigmatization that may come with using PPE and precautions. There’s also the physical space challenge of
nursing homes often lacking private rooms, and in fact, many nursing homes around the
country may have triple or even quad rooms. And then, the difficulty in restricting movement
such as for those residents that are able to move about the facility and the
difficulty in moving residents, especially those that have been
in their location long term. We recognize that we needed an approach to
preventing the spread of MDROs that is specific to nursing homes and takes into
account the unique challenges that are faced in the nursing home setting. This approach must clarify how and
when to use PPE and room restriction. So, for example, when is it appropriate
to place nursing home residents in a strict contact precautions or, as
is often termed isolation, for an MDRO. We also needed a balanced approach to
managing prolonged colonization of MDROs that respects resident rights and dignity
and prioritizes resident quality of life. And, we must also consider the burden of
MDROs in nursing homes which is often unknown or not fully recognized and then develop
a realistic and feasible approach to preventing the acquisition of MDROs by
nursing home residents at highest risk. And so, with this in mind, we have developed
new guidance for nursing homes focused on the implementation of PPE
to prevent the spread of novel or targeted multidrug-resistant organisms. And, in this guidance, we introduce and
define enhanced barrier precautions or EBP and have tried to be as specific
as possible about when EBP versus contact precautions is appropriate as
well as specific guidance on implementation. Enhanced barrier precautions expand the use of
PPE beyond situations in which exposure to blood and body fluids is anticipated,
and it refers to the use of gown and gloves during high contact resident
care activities that provide opportunities for transfer of MDROs to
staff hands and clothing. These high contact resident care activities
include dressing, bathing or showering, transferring, and providing hygiene
such as brushing teeth and combing hair. Activities that are often bundled
into morning or evening care and typically are happening
within a resident room. High contact activities also include changing
linens, assisting with toileting, device care or use of devices such as central
lines, urinary catheter, feeding tube, tracheostomy or ventilators, and wound care. These high contact resident care activities
are informed by nursing home specific research, assessing which resident care
activities were the highest risk of transmitting resistant pathogens from
colonized residents to the gloves and gown of healthcare providers which have
served as a proxy for hands and clothing. For MRSA, the highest risk activities for
transmission including dressing, transferring, providing hygiene, changing
linens, and toileting. Similarly, for antibiotic
resistant gram negative bacteria, the highest risk activities
included toileting and hygiene but also showering and wound dressing changes. The risk of transmission was much lower
for activities such as passing medications and blood glucose monitoring, and
so for activities such as these, PPE would not be required as a part
of enhanced barrier precautions. However, standard precautions always applies. So, for potential exposure
to blood or body fluids such as during blood glucose monitoring,
PPE would still be appropriate. Enhanced barrier precautions should be used
in all nursing home residents with a novel or targeted MDRO and currently, those
are defined as pan-resistant organisms, carbapenemase producing organisms including
Enterobacteriaceae, pseudomonas species, Acinetobacter baumanii, and candida auris. EBP should also be used in all residents with would and/or indwelling medical devices
regardless of MDRO colonization status who are residing in at risk areas. And, for most nursing homes, that at risk
area would be the same unit or the same wing that the MDRO colonized resident is residing on. However, depending on the
public health investigation, infection prevention assessment findings, or
things like movements of residents, staff, or shared medical equipment, that
at risk area may potentially change. So, for an example, if there is an
MDRO colonized resident on one unit, but it’s determined during the
investigation that residents on a second, neighboring unit are also potentially at risk, that at risk area may more appropriately
apply to both of those units. And so, in this situation, you
would, then, identify all residents with wounds and/or indwelling medical
devices residing on either of those units and apply enhanced barrier
precautions for gowns and gloves for those high contact resident care
activities to those identified residents. Given the challenges that have arisen with using
contact precautions in nursing homes for MDROs, this new guidance specifies when using
contact precautions is appropriate. For residents infected or colonized with
novel or targeted MDROs, the only situations for which contact precautions are required
are for residents with acute diarrhea, draining wounds, or other sites of secretions
or excretions that are unable to be kept covered or contained or during an outbreak where
transmission is documented or suspected. For other infections or conditions such
as C. difficile, norovirus, and scabies, contact precautions continues to be the, to be
recommended as per the CDC isolation guidance and specified in appendix a.
There’s not change to the use of contact precautions for these conditions. So, why was the EBP guidance
needed for containment? The current EBP guidance is focused on
MDRO containment because of our experience in needing a way to help facilities
manage additional residents detected as having an MDRO during screening performed
as a part of the public health investigation. Enhanced barrier precautions allows
for an approach that is more specific than standard precautions but is less
restrictive than contact precautions. And, it’s able to be sustained
for a prolonged period of time. EBP also addresses the care of
residents that are at highest risk of acquiring novel or targeted MDROs. So, in terms of PPE and precautions, EBP fits
on the spectrum in between standard precautions where you must make that decision about whether
or not PPE is indicated based on potential risk of exposure and contact precautions
where PPE is worn for all, upon room entry for all activities. Enhanced barrier precautions
specifically requires PPE for those high contact, high
touch resident activities. Our guidance also includes a
description of standard precautions. As a reminder, the standard precautions
applies to all residents at all times, regardless of whether or not
enhanced barrier precautions or contact precautions is being used. And, the PPE required depends
on anticipated exposure. Now, pulling the details
directly from the new guidance but comparing enhanced barrier precautions
side by side with contact precautions to help visualize some of the
similarities and differences. Enhanced barrier precautions should be used for
all residents with infection or colonization with a novel or targeted MDRO when
contact precautions do not apply. So, contact precautions for those MDRO infected
or colonized residents would only apply if that resident had acute diarrhea,
draining wounds, or other sites of secretions or excretions that are unable
to be kept covered or contained. Once that acute diarrhea or drainage has
improved, that resident would be able to be on enhanced barrier precautions. Contact precautions is also
indicated on a unit or in a facility when ongoing transmission
is documented or suspected. So, going back to enhanced barrier precautions,
enhanced barrier precautions also applies to residents with wounds or
indwelling medical devices regardless of their MDRO colonization status who reside
in that same area as the indexed resident with MDRO colonization or infection. And, we are also encouraging facilities to consider applying enhanced
barrier precautions more broadly, which may include applying these precautions
to residents infected or colonized with other epidemiologically important
MDROs and/or to residents with wounds or indwelling medical devices
throughout larger areas of the facility. PPE is used for enhanced barrier precautions
during these high contact resident care activities that we’ve already discussed that
are often bundled into morning or evening care and that include, involve, or include
toileting, device care, and wound care. And, for contact precautions, PPE should be used for any room entry and for
all resident activities. The same PPEs, gloves, and gowns are used for both enhanced barrier precautions
and for contact precautions. But, another very important distinction with
EBP is that a single person room is not required and that residents should not
be restricted to their room or from participating in group activities. Residents in contact precautions should
be considered for a single person room or for cohorting if available
and should be restricted to their room except for
medically necessary care. So, based on our observations in
facilities throughout the country, we’ve included recommendations for
implementation of enhanced barrier precautions as a part of the guidance and these
also apply to contact precautions. It’s very important that signage is displayed
clearly outside of the resident room. A stop sign only saying to see the nurse,
which is what we have commonly observed in nursing homes, is not enough as it does not
communicate the following important information. The sign should indicate the type
of precautions and the required PPE. And, for enhanced barrier precautions, the sign should list the high contact resident
care activities as a reminder to staff. Personal protective equipment should
be available immediately outside of the resident room for all residents on
enhanced barrier precautions or really any form of transmission based precautions including
contact precautions with a plan in place to restock so that supplies do not run out. Because PPE may be necessary as a
part of standard precautions as well, PPE should ideally be available at an easily
accessible location for all residents. And, a trashcan located near the
door is also helpful for staff to discard PPE before exiting the room. Ensure that staff have easy
access to alcohol based hand rub. Ideally, both inside and
outside of every resident room and in other locations where care is provided. Alcohol based hand rub is preferred over soap
and water unless hands are visibly soiled or for C. difficile and norovirus
when an outbreak is occurring. And, increasing access to alcohol based hand
rubs has been shown to help increase adherence to hand hygiene in nursing
homes more than education. So, make it easy for staff
to perform hand hygiene. Ensuring access to cleaning supplies
such as wipes is also important in order to promote cleaning of shared medical
equipment after use with the resident, and for contact precautions, equipment
should ideally be dedicated to the resident. In these pictures, you see some of the methods
that facilities have used to encourage staff to use wipes for shared medical equipment
and for the appropriate contact time, and for clearly dedicating equipment
to residents on contact precautions. Incorporating periodic monitoring and assessment
of adherence for hand hygiene, for PPE use, and for environmental cleaning can
help with providing individual feedback to staff members but, also with assessing the
need for continuing training and education. Moving forward, we are working on
developing additional resources to promote enhanced barrier precautions
such as FAQs and collaborating with nursing home organizations to
evaluate staff education and training, quantify PPE utilization, and develop other
resources for successful implementation, including educational materials
for residents and families. These assessments will include acceptability
and feasibility by staff as well as costs. CDC is also currently funding projects
to evaluate a broad range of strategies to prevent MDRO transmission in nursing homes,
including the efficacy of targeting glove and gown use, the role of
chlorhexidine bathing and decolonization, and the impact of improved
environmental cleaning and infection. We are also working towards establishing
a working group to convene partners from nursing homes as well as the
academic and public health sectors to discuss broader implementation of
enhanced barrier precautions outside of public health containment. You can find many additional resources on
the CDC webpage about containing novel MDROs, candida auris, connecting with
your state public health experts, and a link to the new enhanced
barrier precautions guidance. And, we want to thank you very much
for your time and your interest in combating the spread of MDROs. We look forward to any comments
or questions that you may have.>>Thank you so much, Dr. Stone and Dr.
Jacobs for providing our webinar participants with such important information
about preventing the spread of novel or targeted multidrug-resistant organisms in
nursing homes to enhance barrier precautions. We appreciate your time and
value your clinical insights. We will now go into our Q and A session. Please remember you may submit questions
through the webinar system by clicking the Q and A button at the bottom of your
screen and then typing your question. Again, please do not ask a
question using the chat button. Our first question states why is CDC
only focusing on gown and glove use with enhanced barrier precautions and not
other important infection control measures such as environmental cleaning for
preventing MDRO transmission in nursing homes?>>This is Kara. So, while the guidance, while this guidance
does focus on enhanced barrier precautions, preventing the MDRO – or
prevention of MDRO transmission in nursing homes requires much
more than just proper use of PPE. Adherence to other recommended
infection prevention practices, including preforming hand hygiene, cleaning
and disinfection of environmental surfaces and resident care equipment, proper handling of indwelling medical devices,
and care of wounds is critical. CDC and health departments
continue to identify gaps in recommended infection prevention practices as
a part of on site infection control assessments in nursing homes, and some of those
examples include things like lack of access to alcohol based hand sanitizer in
resident rooms and other care areas, lack of access to EPA registered disinfectants
at the point of use, and failure to clean and disinfect shared resident
equipment after each use. I also want to add that during containment
responses, facilities are provided guidance and support to improving all aspects of their infection prevention practices
in addition to implementing EBP.>>Thank you very much. Our next question asks if a resident
infected or colonized with a novel or targeted MDRO meets criteria
for contact precautions, do I still need to put other residents on
the same unit with indwelling medical devices or wounds or enhanced barrier precautions?>>And, this is Kara again. The answer is yes. Even if the resident colonized with a novel or
targeted MDRO is placed on contact precautions, enhanced barrier precautions is still
recommended for other at risk residents, those that have indwelling medical devices
or wounds in that same unit or ward or area.>>Thank you for that. Our next question asks doesn’t posting
signs specifying the type of precautions and recommended PPE outside the resident
room violate HIPAA and resident dignity?>>This is Kara. No. Signs are intended to signal to individuals
entering the room that the specific actions that they should be taking to
protect themselves and the resident. To do this effectively, the sign needs
to contain information about the type of precautions and the recommended PPE
to be worn when caring for the resident. Generic signs that instruct individuals to
speak to the nurse are not adequate to ensure that precautions are followed, and we’ve often
seen that speaking to the nurse may not happen. So, signs should, and signs should not include
information about the resident’s diagnosis or the reason for precaution
because those, that is information that would violate HIPAA and resident dignity. And, as we showed, as we have shown on
one of the slides in the presentation, CDC has created examples of signs that can be
used by facilities to communicate information about transmission based precautions
and enhanced barrier precautions. And, facilities can use these signs or modify
them to create signs that work for them.>>Thank you. Our next question asks do we have any idea when
the CMS state operations manual will be released and if it will reference enhanced
barrier enhanced standard precautions?>>So, this is Nimalie. It’s a very good question. We have been talking with our colleagues at
the Center for Medicare and Medicaid Services, or CMS, about enhanced barrier precautions
and our guidance and for use of more PPE, especially framed around the containment of emerging antibiotic resistant
organisms throughout the development of the guidance and as a part of the release. And, so they’re aware that there are
going to be more facilities working with public health partners in this containment
response, incorporating gown and glove use as part of resident care in a bigger way. Given how new the guidance is and
that it is framed around containment, it may not be something that
they choose to incorporate into the surveyor guidance
that’s going to be released. However, to be honest, we really can’t say.>>Thank you for that. Our next question asks why would someone
on contact precautions not be advised to participate in group activity?>>So, people are placed, this is Nimalie again. People are placed into contact precautions when
they have a communicable pathogen with a lot of risk for transmission into the environment
and contamination into the environment. And, for the window of time when that
kind of risk of spread is greatest, that is when we recommend that those
individuals with those clinical syndromes or infections are not involved
in group activities. However, as soon as the issue,
whether it is acute diarrhea or challenges containing secretions,
as soon as those issues have resolved, then contact precautions can be transitioned
to something like enhanced barrier precautions. It’s really containing people during the highest
risk point in a communicable infectious disease.>>Thank you. Our next questions states how long should a
resident remain on enhanced barrier precautions?>>So, the way that enhanced barrier
precautions has been intended to be applied, oh, sorry, and this is Kara. But, the way that enhanced barrier precautions
has intended to be applied is for the duration of that resident’s stay at the facility. It is possible if an enhanced or if a resident
was placed in enhanced barrier precautions due to something like a wound or an indwelling
medical device and that wound has since resolved or the device is no longer in place, then
that resident may be able to be taken out of enhanced barrier precautions with
standard precautions alone being used.>>Thank you. The next question asked what
is the best practice or opportunities to identify
colonized residents?>>That is a very good questions and a difficult
one to answer because as we talked about, often the risk factors and the exposures
that an individual might come to a facility with that puts them at risk for being
colonized with an MDRO might be things that you’re aware of, but their actual status, their MDRO status may not be
information readily accessible. So, one of the benefits of the enhanced
barrier approach is the risk based approach to application of gowns and
gloves where you’re not relying on knowing whether somebody is colonized,
but you’re looking at the potential they have to either already be colonized or to be at high
risk for acquisition and you’re using gowns and gloves during their care
as a protective measure. In other post acute care settings
like long term acute care hospitals, many have employed active
surveillance for new admissions where they’re actually obtaining swabs of
very spotty sites like the nose or the axilla and groin, looking for the presence of
resistant organisms colonizing those individuals as they’re coming into the facility. And, that’s a strategy that can work, especially when you’re caring
for a very high risk population. However, there have to be some decisions about
how to offer and build that kind of a process into your workflow if you’re going to
consider active surveillance screening for new admissions.>>Thank you. Our next inquirer asks as I read
the EBP guideline, it states novel or targeted MDROs are defined
as and lists five categories. This does not include MRSA and VRE as I read it. Is that correct? It is currently proposed for
those novel or targeted MDROs?>>This is Kara. Yes, that is correct. The current guidance is focused
on containment activities and specifically those targeted pathogens. However, we do encourage facilities to
consider applying enhanced barrier precautions to other epidemiologically relevant or
important organisms at their facility. And, we are also considering and
investigating the application of enhanced barrier precautions
more broadly to other organisms.>>Thank you. Our next question states on the
high contact activities slide, should the list also include therapy activities? If not, what precautions should be
taken for these residents in therapy?>>This is Kara again. And so, that high contact, the slide that includes the high contact resident care
activities are focused around activities that have been investigated in nursing home
settings that have been specific to activities that are typically preformed
within the resident room. However, it really, for physical therapy,
there may be high contact activities. And so, it really depends on
what is being done during therapy and therapists should consider the use of gowns
and gloves when they are working with residents on enhanced barrier precautions in the
therapy gym if they are anticipating that close and prolonged contact. When assisting them with things like
transfers or mobility, but also as a part of standard precautions,
gloves and gowns should, may be indicated based on potential exposure. And, then they should be removed
and hand hygiene should be performed when moving to work with another resident. Therapists should also be ensuring that reusable
therapy equipment is cleaned and disinfected after each use and that surfaces in the
therapy gym are receiving regular cleaning and disinfection.>>Thank you. Our next inquirer asks do you discontinue EBP
with a negative culture or swab and return to SB or are EBP ongoing once MDRO is ID’d?>>So, this is Nimalie. The role of rescreening is something that comes
up quite often as a question when thinking about use and implementation of precautions and
can we stop these precautions at some point. As Kara mentioned earlier, the way enhanced
barrier precautions is being rolled out, it’s really meant to be a more sustainable
approach to gown and glove use during care because we know that [inaudible] carriage can
be quite prolonged, especially in individuals who continue to have a lot of functional
dependence and high risk care needs that continue to make them more
vulnerable to retaining those organisms. In addition, a challenge with retesting
or rescreening to see if, you know, carriage has been cleared is that there’s
reliability of those tests is quite variable and often can lack sensitivity, meaning you may
get a negative swab result and it turns out, in fact, that individual still
remains colonized with that MDRO. So, it is not a practice that we are
routinely recommending as a measure to remove somebody from precautions.>>Thank you. Our next question asks if it is
difficult to know the colonization status, shouldn’t all residents with
indwelling devices and wounds have EBP?>>So, this is Nimalie. Yes, actually. We 100% agree with that sentiment, and
as Kara alluded to, we are exploring ways that enhanced barrier precautions
might be applied more broadly in nursing homes outside of
an AR containment response. And, that is certainly a very
pragmatic, forward thinking approach that we would encourage facilities to consider. Even those that may not be aware of a novel or
emerging pathogen in their resident population. But, if you care for a very
high risk group of residents, that would be a very smart strategy to consider.>>Thank you. The next questions asks why are you recommending
alcohol based hand sanitizer instead of hand washing?>>Well, since 2002, the CDC hand hygiene
guidelines have identified alcohol based hand rubs as the preferred method
for hand disinfection in most clinical situations except when, you
know, hands are visibly or grossly soiled. Because we have seen many, many studies
demonstrate the improved efficacy of the alcohol based hand rubs
over hand washing when it comes to decontamination of organisms on hands. There are reasons for that that include use
of alcohol based products are not as dependent on technique, and with hand washing, there have
to be quite a lot of attention to getting soap on all of the right surfaces and
also for the right duration of time. And, if you spend time in healthcare facilities
and observe caregivers who are very busy people, they don’t have, often, the same amount
of time that they need to be effective with their hand washing technique. So, that alone is a major reason why alcohol
based hand products are more effective. In addition, there can be
more accessible than sinks. If you think about it, you know, in any
building, you may be able to put more dispensers up to make alcohol based products more
available, but it’s often hard to replumb or add new piping, so it’s harder
to make sinks more available. And, as Kara mentioned, the increased access to alcohol based hand dispensers
does improve hand hygiene in nursing homes and other healthcare settings.>>One of the common questions that
we’re seeing from our inquirers is where can they acquire these signs.>>So, the signs are on our website, and they’re
actually the enhanced barrier precautions sign is linked directly to the EBP
guidance on our containment website. There is, actually, a hyperlink to the other
transmission based precaution signs as well. And, they’re also found on our website for implementing transmission based
precautions in healthcare facilities. We can make sure some of those links are on the COCA call website as
well as additional resources. Thanks for the question.>>Thank you. Our next question asks are these new precautions
applicable to acute care facilities and LTACs?>>So, currently, the enhanced barrier
precautions guidance is applicable in the nursing home settings. For the other settings, you would continue
to follow the CDC isolation guidelines. This is Kara speaking.>>Thank you very much. Our next question asks when
does this go into effect?>>This is Kara. The guidance, this guidance was
published to the CDC website in July of this year and is already in effect. And, in fact, has been being used as a
part of containment responses and work between facilities and CDC and health
departments for more than a few months now. So, we encourage you to continue
to familiarize yourself with it as it is being implemented currently.>>Thank you very much. We have time for one more question, and the
question states if we screen the infected or colonized resident and confirm they
are no longer colonized with the novel or targeted MDRO, may we stop
using enhanced barrier precautions?>>Yes. So, it is, I totally
appreciate this Nimalie. I appreciate the desire to be able to remove
somebody out of enhanced barrier precautions if you’re able to demonstrate through
rescreening that they’ve cleared. And, just so people are aware, a single
repeat swab is inadequate to determine that somebody has cleared
their colonization status. There are some parameters that
need to be followed if you’re going to even consider doing rescreening,
including waiting at least six months from the original detection of an
organism before you would be eligible to consider rescreening. And, also ensuring that they have been
off of any antibiotics or therapies for that particular organism or in general
prior to doing the repeat screening test. There have to be, at a minimum, two negative
cultures at least two weeks apart in order to verify that somebody’s status is no
longer detectable and that’s because, as I mentioned earlier, there’s a poor
reliability of single swab to verifying that somebody’s genuinely cleared. When we have followed individuals for prolonged
periods of time on the order of months, we find that they can have intermittent
negative cultures followed by positive cultures, and that’s often when their
health status has worsened or they’ve been reexposed to antibiotics. So, you really have to think about what is
the ongoing care and needs of the person that I’m trying to demonstrate that they’ve
cleared their carriage before feeling confident that that negative test will remain negative. The other thing I would say is that if the
facility has been using enhanced barrier precautions in the care of this person
because of a novel organism and even if they can no longer detect that organism,
the resident continues to have a wound or a medical device that makes them still
eligible for EBP because of their ongoing risk for acquisition, then they
would be encouraged to retain and keep using enhanced barrier
precautions in their care.>>Thank you very much. This concludes our Q and A session. We received a tremendous amount of questions
today, so if you were not able to get to your question due to time constraints,
please note that you can send your questions to [email protected], and we will share
your question with our presenters. We will, then, share their
responses with you via email. On behalf of COCA, I would like to
thank everyone for joining us today with a special thank you to our
presenters, Dr. Stone and Dr. Jacobs. This webinar will be available to view
on demand within the next few days on the COCA website at emergency.cdc.gov/coca. Again, that web address is
emergency.cdc.gov/coca. All continuing education for COCA calls
are issued online through TCE online, the CDC training and education, continuing education online
system at www.cdc.gov/tceonline. Those who participated in
today’s COCA call and would like to receive continuing education
should complete the online evaluation by November 25, 2019 and use course code WC2922. Those who will view the webinar
on demand and would like to receive continuing education
should complete the online evaluation between November 25, 2019 and November
26, 2021 and use course code WD2922. Please join us for our next scheduled COCA
call on Tuesday, December 10 at 2:00 PM eastern where the topic will be updated
guidance for using intravenous artesunate for treating severe malaria
in the United States. To receive information on upcoming COCA
calls or other COCA products and services, try the COCA mailing list by visiting the COCA
webpage at emergency.cdc.gov/coca and click on the join the COCA mailing list. To stay connected to the latest news from
COCA, be sure to like and follow us on Facebook at facebook.com
/cdcclinicianoutreachandcommunicationactivity. Again, thank you for joining
us for today’s webinar. Enjoy the rest of your day.

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