Author: Susan Peschin, MHS
Date: November 16th, 2015
As we kick off Get Smart about Antibiotics Week, some thoughts from our President and CEO Susan Peschin:
Newer and more virulent infections in long-term care settings are changing the image of a loved one “fading quietly into the night” into a nightmare of suffering. Of the more than four million Americans in U.S. nursing homes, skilled nursing facilities, and assisted living facilities, the Centers for Disease Control and Prevention (CDC) estimates that each year 380,000 die due to healthcare-associated infections (HAIs).
In an effort to reduce that concerning number, the Centers for Medicare & Medicaid Services (CMS), the government agency responsible for several key federal health care programs, issued a proposed rule change on infection prevention and control in long-term care facilities that is set to be finalized in the coming weeks. This is a significant step because much has changed in the infection-control landscape in the 23 years since CMS last updated its guidance.
Unfortunately, the proposed CMS rule is currently too broad to make a dent. Without mandates for specific rules on antibiotic stewardship, infection surveillance, prevention, and control, many of these otherwise preventable deaths will continue unabated.
Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70 percent of residents receiving one or more courses of systemic antibiotics in a year. Yet studies have shown that 40–75 percent of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for nursing home residents, including increased risk of serious diarrheal infections, adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms—an increasingly alarming public health issue.
Take for example Clostridium difficile (C. difficile), a deadly infection that causes inflammation of the colon and one that the CDC has identified as an urgent threat. In February 2015, the CDC released a study finding that more than 100,000 C. difficile infections develop in U.S. nursing homes residents each year. And patients who take antibiotics are most at risk for developing C. difficile infections. Unnecessary antibiotic use and poor infection control may increase the spread of C. difficile within and among facilities.
Yet CMS provides no guidance in its proposed rule about how facilities should perform antibiotic stewardship, which is a coordinated plan designed to optimize treatment of infections and promote appropriate use of antibiotics. CMS would do well to mandate the CDC’s evidence-based “Core Elements of Antibiotic Stewardship for Nursing Homes.” This program would also provide state surveyors—those charged with investigating facilities—with something concrete to help them monitor effectiveness.
Another concern with the proposed rule is the absence of instruction on how to conduct infection surveillance. Infection surveillance can give long-term care facilities information to monitor problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections. CDC research shows that when health care facilities, care teams, and individual practitioners are aware of infection problems and take specific steps to prevent them, certain infection rates can decrease by more than 70 percent.
Currently, all CMS-certified nursing facilities use the Minimum Data Set (MDS) for collecting information on infections in longer-stay residents. However, the U.S. Department of Health and Human Services (HHS)—the umbrella agency that effectively serves as CMS’ boss—notes in its 2013 National Action Plan to Prevent Health Care-Associated Infections that “there are limitations to using MDS data as a universal data source to track HAI in nursing homes.” The concern is that the assessments provide data at a particular point in time, and that the time between assessments—often only quarterly—may not capture important changes, including new infection events. Additionally, the MDS is not capable of capturing multiple infections, timing of infections, or any information on short-stay residents admitted from the hospital setting for rehab. The goal of calculating infections should not be just to count, but rather to see the full picture of infection patterns and to identify places to intervene.
For several years, hospitals and other acute care settings have been using the CDC’s National Health Safety Network (NHSN) surveillance system to track infections. Currently, 32 states and the District of Columbia are required by law to report HAI data in hospitals and other acute care settings to the NHSN, with more than 17,000 facilities participating. CMS should require nursing homes and skilled nursing facilities to adopt NHSN for infection surveillance.
NHSN data should also be translated for use in CMS’ Nursing Home Compare rating system to educate consumers about rates of infection by facility, and whether or not a facility has implemented the CDC’s antibiotic stewardship program. Nursing Home Compare has detailed information about every Medicare and Medicaid-certified nursing home in the country and ratings are provided for health inspections, staffing, and quality measures. Since nursing homes vary in the quality of care and services they provide to their residents, adding a rating for infection control and antibiotic stewardship would educate consumers on an important aspect of health safety as they choose a facility.
Last, CMS should include a mandate that all long-term care employees who have direct contact with residents be required to get an annual flu vaccine. According to the CDC, "flu vaccination coverage was lowest among health care personnel working in long-term care facilities (54.4 percent)." Residents of long-term care facilities are particularly susceptible to contracting influenza because of often compromised immune systems, and because their health care setting is often their home.
CMS has an opportunity to make a huge difference here. Until they do, healthcare-associated infections will literally remain a life-and-death issue for our nation’s long-term care residents.