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All right, well, welcome
everyone.
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Thank you for joining us for the
May 22nd, 2024 Long Term Care
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Town Hall: Understanding Enhanced
Barrier Precautions.
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We are very thankful for the
support and collaboration of the
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Centers for Disease Control and
Prevention's Project First Line,
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which has enabled us to provide
this webinar to you all as
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quickly as possible after
learning about the recent EBP
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enforcement memo.
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I'm Commander Kara Jacobs
Slifka.
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I'm a medical officer with the
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CDCs long term care team.
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I lead our Long term care team
here within the Division of
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Healthcare Quality Promotion.
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I'm really excited to introduce
the two members of the Long term
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care team who we will be
presenting this webinar, Doctors
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Bola Ogundimu and Heather Jones.
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Dr.
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Ogundimu is a nurse infection
preventionist and health
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scientist.
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In her role, she provides
consultation and technical
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assistance for implementing
infection prevention and control
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strategies in post acute and
long term care settings in
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collaboration with state and
local health departments across
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the United States.
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Doctor Ogundimu currently leads
work focusing on the
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intersection between health
disparities and infection
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prevention.
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Doctor Heather Jones serves as a
Nurse consultant, having begun
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her healthcare career as a
registered nurse in acute care
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and then as a family Nurse
Practitioner working alongside
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medical directors and staff in
nursing homes.
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In 2020, she received her
doctorate in nursing practice
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and began her public career
public health career with CDC.
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Doctor Jones provides infection
prevention and control subject
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matter expertise for post acute
and long term care outbreak
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responses and has presented at
many local and national
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conferences.
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Doctor Jones is currently
leading efforts for better
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understanding the role of
infection preventionists in long
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term care settings.
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right.
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And I've already shared our
disclosure, so I will not repeat
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those.
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Thank you everyone for joining
us again today.
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I'm going to now do a little bit
of a presentation of the iceberg
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effect and many of you that have
been in our long term care calls
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before as well as know anything
about infection and colonization
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and MDROs will be quite
familiar with the iceberg
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effect.
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So to begin, when we think about
the iceberg and we think about
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the tip, this is the tip of the
iceberg and this is what we see.
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And so the tip of the iceberg is
clearly visible to everybody and
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it depicts what we already know
or what we physically see or
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know about a patient or a
resident.
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A MDRO infection is the tip of
that iceberg.
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And when a person has an MDRO
infection, they have presence of
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signs and symptoms in the
resident or patients.
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Or another way to look at this
is if a person has a documented
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infection or colonization with
the MDRO and it is present in
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their healthcare record.
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So you see this and you know
this.
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It isn't a part of what we know
as the larger unseen part.
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What we don't see or we don't
know.
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And this is the large portion
that's hidden below the surface.
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This is what we often discuss
when talking through a MDRO
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colonization or multi drug
resistant organism.
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A MDRO colonization is when a
resident has the presence of an
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MDRO that is not causing signs
and symptoms or it's not present
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in their medical record or their
healthcare records.
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So you do not know that they are
colonized with the MDRO and
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Here's the whole picture.
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So when we think about the whole
picture, this is where the
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prevention strategies come into
play.
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If you don't see or know the
large unseen portion of MDRO
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colonization, and you're only
aware of the few residents who
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have a known MDRO infection or
colonization in a nursing home,
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you must have prevention
strategies in place to stop the
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spread of all unknown MDRO's.
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A recent study found that only a
small portion of residents in
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the study were already known to
have an MDRO, but when they
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began to actively look for
MDROs in these residents of
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these nursing homes, they
actually found that one out of
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every two were found to have the MDRO.
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So we wanted to establish the
basis of why there is an
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importance for having prevention
strategies including enhanced
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barrier precautions.
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And now I'm going to turn it
over to Bola who is going to be
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speaking a little bit more about
those.
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Thank you so much Heather.
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And so for exploring again like
a rationale as well as a or
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exploration of enhanced barrier
precautions as noted in the next
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slide.
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So we have enhanced barrier
precautions as an infection
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prevention and control strategy
that is really designed to
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reduce transmission of multi
drug resistant organisms
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otherwise known as MDROs in our
nursing homes specifically.
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So EBP enriches enhanced barrier precautions.
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It involves again the use of
gown and gloves that is focused on
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resident care activities most
likely leading to the spread of
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MDROs in our nursing home
facilities.
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Next slide please.
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So as a refresher, going through
the different types of
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precautions that we have,
starting out with the standard
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precautions, we recognize the
standard precautions a pair or
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apply to the care of all
residents where the use of PPE
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is really based on anticipated
exposure to blood, body fluids,
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secretions as well as
excretions.
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So for instance, gloves are
recommended when we someone a
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healthcare personnel will be in
contact with blood or
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potentially infectious
materials, mucous membranes as
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well as non intact skin or
contaminated equipment.
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If it's anticipated that that
interaction will occur. Again
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going that is standard
precautions.
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And so in contrast or or
sometimes in complements with
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their enhanced barrier
precautions, which is the use of
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gown and gloves beyond the
anticipated blood and body fluid
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exposure.
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And again, enhanced barrier
precautions focuses on gowns and
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gloves that are used during high
contact resident care activities
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that have been shown to result
in the to decreased transfer of
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MDROs to hands and clothing.
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So again, to prevent transfer of
MDROs to the hands and
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clothing of health care
personnel, even if blood and
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body fluid exposure is not
anticipated. Point to note is
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that standard precautions could
still apply even when you're
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using an EBP.
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So for instance, if it's
anticipated that for a procedure
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there will be splashes or
sprays or interactions with the
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residents, if splashes or sprays
are anticipated during high
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contact resident care
activities, face protection
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really should be used in
addition to the gown and gloves.
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So essentially standard
precautions plus enhanced
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barrier precautions where you
anticipate that there's another
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level of body fluid exposure.
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Next, we have contact
precautions and that actually
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requires the use of gown and
gloves on every single entry
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into a resident's room regardless
of the level of care that is
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being provided to the resident.
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So contact precautions are
generally intended to be
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time limited and when they're
implemented, there should be a
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definitive plan or at least a
possible plan for
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discontinuation or de-escalation
of the contact precautions.
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And then the resident is
actually given a lot of times
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dedicated equipment, the
stethoscope, blood pressure
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cuff, sometimes dynamaps and is
placed in the private room
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setting specifically for
contact precautions.
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And then we also say when
private rooms are not available,
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some residents typically we say
grouped like residents together.
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so some residents may be cohorted or grouped together
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and then also residents of
contact precautions should be
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restricted to their rooms except
for medically necessary
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care and they also restricted
some participation of group
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activities.
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So again, those are the contrast
between standard precautions,
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enhanced barrier precautions and
contact precautions.
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And just reiterating again,
enhanced barrier precautions
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will be gown and gloves used,
but if you anticipate there's
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additional like body fluid
exposure, then standard
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precautions would also be used
in addition to enhanced barrier
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precautions. Next slide.
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So at a minimum, enhanced barrier
precautions are intended to be
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used for residents colonized or
infected with MDROs targeted
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by the CDC.
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We've often gotten questions
about what do we mean by CDC
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targeted MDROs.
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So I'll be going over that the
next couple of seconds.
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So for the next slide, So what
do we mean by a targeted MDRO?
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So essentially targeted MDRO's
are germs that are resist
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resistant to most or all
available antimicrobial agents
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and have the potential to spread
widely and intensive public
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health actions are typically
required to slow the spread of
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targeted MDROs.
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And next slide we have a couple
of examples.
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So just off this list on the
slide we have
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Pan-resistant organisms which I mentioned
earlier as well as carbapenemase
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producing carbapenem-resistant
Enterobacterales and then also
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carbapenemase-producing carbapenem-resistant
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Pseudomonas species and also
Carbapenemase-producing
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carbapenem-resistant is the
Acinetobacter baumannii which
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also some is known as crab and
then Candida auris is another
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example.
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So next slide, it is important
to note that in addition,
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residents should have MDRO
prevention strategies in place
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for residents at high at an
increased or higher risk of
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being colonized or already
colonized or infected.
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And we would be using EBP for
residents with indwelling
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medical devices essentially as
an MDRO prevention strategy
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that could be used or that
may be used for this group of
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residents with increased risk.
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So the first increased risk
would be residents with
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indwelling medical devices such
as indwelling foley catheters or
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indwelling urinary catheters,
tracheostomies, ventilators as
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well as central venous catheter
like PICCs or ports.
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And then for the purposes of
EBP, we had also added midline
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catheters in addition to that.
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So next slide, we have also EBP
may be used for residents that
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have a wound.
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So we got a lot of questions
about wounds.
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Like what?
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What do we mean by wounds?
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So we're not talking short term
wounds that you can apply
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band-aid kind of dressing on.
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We're talking more chronic
wounds like pressure ulcers or
266
00:13:50,233 --> 00:13:56,100
diabetic foot ulcers as
well as chronic venous stasis
267
00:13:56,100 --> 00:14:00,966
ulcers as we recognize that
chronic wounds are risk factors
268
00:14:00,966 --> 00:14:02,400
for MDROs.
269
00:14:02,400 --> 00:14:03,233
270
00:14:03,233 --> 00:14:11,700
And so the other next slide we
have is just thinking through
271
00:14:11,700 --> 00:14:15,333
our EBP versus contact
precautions.
272
00:14:15,333 --> 00:14:19,600
So we've often gotten questions
about, well who needs contact
273
00:14:19,600 --> 00:14:23,266
precautions instead of enhanced
barrier precautions.
274
00:14:23,266 --> 00:14:30,333
Still to answer that question
again, recognize that EBP is
275
00:14:30,333 --> 00:14:36,166
specific for MDROs prevention
specifically in nursing homes
276
00:14:36,166 --> 00:14:41,433
and so Appendix A of the
isolation guidelines would still
277
00:14:41,433 --> 00:14:43,400
apply for other pathogens.
278
00:14:43,400 --> 00:14:43,833
279
00:14:43,833 --> 00:14:50,133
So in your facility or in any
facility, specifically nursing
280
00:14:50,133 --> 00:14:56,400
homes, if a resident, for
instance, has certain conditions
281
00:14:56,433 --> 00:15:01,200
where there might be possible
transmission if not contained,
282
00:15:01,200 --> 00:15:04,833
then contact precautions should
be implemented.
283
00:15:04,833 --> 00:15:05,466
284
00:15:05,466 --> 00:15:11,900
So those examples would include
for a facility that has
285
00:15:11,900 --> 00:15:14,733
residents, for instance, with
acute diarrhea.
286
00:15:14,733 --> 00:15:15,000
287
00:15:15,000 --> 00:15:19,766
For those residents, contact
precautions will be in place as
288
00:15:19,766 --> 00:15:24,933
well as residents that have
draining wounds that can't be
289
00:15:24,933 --> 00:15:30,133
contained or covered like they'd
have weeping wounds, contact
290
00:15:30,133 --> 00:15:31,833
precautions would be
implemented.
291
00:15:31,833 --> 00:15:32,100
292
00:15:32,100 --> 00:15:40,433
And then also if there are
conditions where the
293
00:15:40,433 --> 00:15:44,900
resident is unable to contain
their excretions, for instance,
294
00:15:44,900 --> 00:15:49,100
for cases like C diff where or
even norovirus where they might
295
00:15:49,100 --> 00:15:54,733
have explosive diarrhea, then
contact precautions would be
296
00:15:54,733 --> 00:15:55,866
implemented.
297
00:15:55,866 --> 00:15:56,133
298
00:15:56,133 --> 00:16:01,500
And again, it's just secretions
or excretions that can't be
299
00:16:01,500 --> 00:16:04,833
covered or contained. Next slide.
300
00:16:04,833 --> 00:16:06,100
301
00:16:06,100 --> 00:16:14,000
So we also have situations where
as I indicated earlier, other
302
00:16:14,000 --> 00:16:19,100
situations outside of not being
able to contain or cover whether
303
00:16:19,100 --> 00:16:23,666
it's a wound, weeping wound or
on excretion.
304
00:16:23,666 --> 00:16:24,133
305
00:16:24,133 --> 00:16:30,300
Also have situations where if a
facility has a suspected or
306
00:16:30,300 --> 00:16:34,433
confirmed MDRO outbreak in
working together with the public
307
00:16:34,433 --> 00:16:40,800
health department and often
times it is directed by the
308
00:16:40,800 --> 00:16:43,933
public health department or
public health authorities
309
00:16:43,933 --> 00:16:44,000
310
00:16:44,000 --> 00:16:49,000
investigations, that contact
precautions is in place again
311
00:16:49,000 --> 00:16:51,333
for a time limiting period.
312
00:16:51,333 --> 00:16:52,266
313
00:16:52,266 --> 00:16:57,200
And this is generally intended
again to be time limited.
314
00:16:57,200 --> 00:16:57,266
315
00:16:57,266 --> 00:17:00,633
And when implemented there
should be a plan for
316
00:17:00,633 --> 00:17:03,700
discontinuation or de-escalation.
317
00:17:03,700 --> 00:17:04,500
318
00:17:04,500 --> 00:17:10,500
And also not all MDRO outbreaks
may need the use of contact
319
00:17:10,500 --> 00:17:10,833
precautions.
320
00:17:10,833 --> 00:17:14,866
Again, we encourage you to work
with your public health
321
00:17:14,866 --> 00:17:20,000
department to really go through
with different steps of your
322
00:17:20,000 --> 00:17:22,933
outbreak investigation in
collaboration with them.
323
00:17:22,933 --> 00:17:23,700
324
00:17:23,700 --> 00:17:24,500
Next slide.
325
00:17:24,500 --> 00:17:25,900
326
00:17:25,900 --> 00:17:33,300
So we've often gotten these
questions regarding what the CDC
327
00:17:33,300 --> 00:17:39,000
defines or you know it gives
examples of high contact
328
00:17:39,000 --> 00:17:40,700
resident care activities.
329
00:17:40,700 --> 00:17:48,200
So those activities include,
first off, things like dressing,
330
00:17:48,200 --> 00:17:55,566
bathing or showering, as well as
transferring the residents one
331
00:17:55,566 --> 00:18:01,533
spot to the other from bed to
chair and vice versa.
332
00:18:01,533 --> 00:18:01,800
333
00:18:01,800 --> 00:18:07,000
And also providing hygiene and
changing bed linens as well as
334
00:18:07,000 --> 00:18:12,066
changing sheets or assisting a
resident with toileting as
335
00:18:12,066 --> 00:18:16,266
well as handling their
indwelling medical device.
336
00:18:16,266 --> 00:18:18,066
337
00:18:18,066 --> 00:18:22,833
And also if we're gonna be
assisting with maintaining their
338
00:18:22,833 --> 00:18:27,066
indwelling medical devices, that
gowns and gloves would be needed
339
00:18:27,066 --> 00:18:28,800
for those circumstances.
340
00:18:28,800 --> 00:18:29,133
341
00:18:29,133 --> 00:18:33,000
And again, when we talk about
wound care, as I illustrated
342
00:18:33,000 --> 00:18:37,433
earlier, we don't necessarily
need the shorter lasting
343
00:18:37,433 --> 00:18:38,700
Band-Aid wounds.
344
00:18:38,700 --> 00:18:39,333
345
00:18:39,333 --> 00:18:43,833
We're talking more chronic
wounds and a lot of times we
346
00:18:43,833 --> 00:18:48,033
often say that those resident
care activities that are shown
347
00:18:48,033 --> 00:18:52,766
on this slide, the high contact
resident care activities should
348
00:18:52,766 --> 00:18:55,066
be bundled as much as possible.
349
00:18:55,066 --> 00:18:59,166
So if you're doing AM care, it
is important to consider what
350
00:18:59,166 --> 00:19:05,433
else you can have in place as
maybe being able to group
351
00:19:05,433 --> 00:19:08,033
together the different
activities that can be done.
352
00:19:08,033 --> 00:19:08,133
353
00:19:08,133 --> 00:19:12,800
And the next couple of slides
will show certain examples of
354
00:19:12,800 --> 00:19:17,833
what can be done for facilities
while they're bundling different
355
00:19:17,833 --> 00:19:19,800
resident care activities.
356
00:19:19,800 --> 00:19:20,466
357
00:19:20,466 --> 00:19:21,100
Next slide.
358
00:19:21,100 --> 00:19:22,200
359
00:19:22,200 --> 00:19:22,600
OK.
360
00:19:22,600 --> 00:19:23,333
361
00:19:23,333 --> 00:19:28,966
So again, many of the high
contact resident care activities
362
00:19:28,966 --> 00:19:35,133
are typically bundled inside the
room as part of AM or PM care as
363
00:19:35,133 --> 00:19:36,633
I noted earlier.
364
00:19:36,633 --> 00:19:37,666
365
00:19:37,666 --> 00:19:41,800
So for instance, on the left
side of the slide that is
366
00:19:41,800 --> 00:19:47,233
circled in in red, activities
such as helping the resident use
367
00:19:47,233 --> 00:19:52,266
the toilet or toileting, helping
them getting freshened up as
368
00:19:52,266 --> 00:19:56,966
well as helping them get dressed
or change bed linens and
369
00:19:56,966 --> 00:20:00,933
transferring the resident
from bed to chair.
370
00:20:00,933 --> 00:20:01,000
371
00:20:01,000 --> 00:20:05,666
Vice versa can be bundled
together during one interaction
372
00:20:05,666 --> 00:20:07,100
with the resident.
373
00:20:07,100 --> 00:20:07,400
374
00:20:07,400 --> 00:20:11,233
So otherwise we call it AM care
in some instances.
375
00:20:11,233 --> 00:20:11,800
376
00:20:11,800 --> 00:20:16,466
In another instance on the right
activities such as assessing
377
00:20:16,466 --> 00:20:22,000
wound care, dressing or changing
wound dressings as well as
378
00:20:22,000 --> 00:20:28,366
performing skin
assessment and also assessing
379
00:20:28,366 --> 00:20:31,666
their feeding tubes or giving
medications through their
380
00:20:31,666 --> 00:20:36,100
feeding tubes also can be
bundled together or can be
381
00:20:36,100 --> 00:20:41,833
provided at certain intervals
rather than just using a single
382
00:20:41,833 --> 00:20:43,900
entry into that resident鈥檚 room.
383
00:20:43,900 --> 00:20:45,333
384
00:20:45,333 --> 00:20:53,833
So next slide we have again EBP
is generally not necessary for
385
00:20:53,833 --> 00:20:58,233
brief minimal touch interactions
with the residents.
386
00:20:58,233 --> 00:20:58,600
387
00:20:58,600 --> 00:21:02,600
And also if the
healthcare personnel is not
388
00:21:02,600 --> 00:21:06,433
necessarily touching the
resident or environment inside
389
00:21:06,433 --> 00:21:10,333
the room, then EBP is not
needed.
390
00:21:10,333 --> 00:21:10,833
391
00:21:10,833 --> 00:21:16,066
So for instance, if there is
anticipated isolated foaming of
392
00:21:16,066 --> 00:21:21,533
the residents pair that is not
otherwise bundled with other
393
00:21:21,533 --> 00:21:25,600
high contact resident care
activities, then that
394
00:21:25,600 --> 00:21:30,433
interaction would not
necessarily mean gown and gloves,
395
00:21:30,433 --> 00:21:34,900
essentially no EBP for that only
isolated instance.
396
00:21:34,900 --> 00:21:35,700
397
00:21:35,700 --> 00:21:36,500
Next slide.
398
00:21:36,500 --> 00:21:37,866
399
00:21:37,866 --> 00:21:45,466
So again as to why we have EBP
being recommended, we've looked
400
00:21:45,466 --> 00:21:49,633
at multiple studies over the
years and over the next couple
401
00:21:49,633 --> 00:21:53,466
of slides we wanted to share
different studies that have
402
00:21:53,466 --> 00:21:58,666
looked at high contact resident
care activities that have
403
00:21:58,666 --> 00:22:02,300
resulted in the highest spread
of MDROs.
404
00:22:02,300 --> 00:22:02,733
405
00:22:02,733 --> 00:22:08,066
So as you can see on this slide
with the bars, the highest risk
406
00:22:08,066 --> 00:22:13,466
activities included those where
we recommend gown and gloves to
407
00:22:13,466 --> 00:22:17,200
be used in the current EBP
recommendations.
408
00:22:17,200 --> 00:22:18,033
409
00:22:18,033 --> 00:22:22,100
Again, these slides will be
available to everybody after the
410
00:22:22,100 --> 00:22:24,833
town hall. Next slide.
411
00:22:24,833 --> 00:22:25,500
412
00:22:25,500 --> 00:22:30,700
We also showed similar results
with other studies that others
413
00:22:30,700 --> 00:22:37,333
have done, really indicating the
highest risk activities that
414
00:22:37,333 --> 00:22:40,400
that force the most MDRO spread.
415
00:22:40,400 --> 00:22:40,933
416
00:22:40,933 --> 00:22:45,333
Again, the importance of having
data from these nursing homes
417
00:22:45,333 --> 00:22:46,833
cannot be overstated.
418
00:22:46,833 --> 00:22:47,333
419
00:22:47,333 --> 00:22:51,700
So observations of the types of
care activities that are
420
00:22:51,700 --> 00:22:56,066
performed in nursing home
residents and which activities
421
00:22:56,066 --> 00:23:00,333
are found to be the highest risk
of spreading MDROs to
422
00:23:00,333 --> 00:23:04,266
healthcare personnel, which
could then spread to other
423
00:23:04,266 --> 00:23:09,100
residents and even themselves
really directly influenced by
424
00:23:09,100 --> 00:23:10,100
EBP guidance.
425
00:23:10,100 --> 00:23:12,500
426
00:23:12,500 --> 00:23:14,433
And then we have the next slide,
427
00:23:14,433 --> 00:23:15,100
428
00:23:15,100 --> 00:23:19,900
So with the previous studies
that I had noted earlier, again
429
00:23:19,900 --> 00:23:24,500
really these high contact
activities have the most spread.
430
00:23:24,500 --> 00:23:25,266
431
00:23:25,266 --> 00:23:30,233
But this particular slide that, this particular slide
432
00:23:30,233 --> 00:23:36,200
denotes like how targeted gown
and glove use also known as EBP
433
00:23:36,200 --> 00:23:39,933
or enhanced barrier precautions
successfully reduced the
434
00:23:39,933 --> 00:23:41,666
transmission of MDRO.
435
00:23:41,666 --> 00:23:42,133
436
00:23:42,133 --> 00:23:47,100
So this study in particular
demonstrated that nursing homes
437
00:23:47,100 --> 00:23:51,200
were able to successfully
identify residents with risk
438
00:23:51,200 --> 00:23:55,833
factors for MDROs as I
indicated earlier and also
439
00:23:55,833 --> 00:24:01,100
obtained an excellent adherence to
the focus use of gown and gloves
440
00:24:01,100 --> 00:24:05,733
meaning EBP by healthcare
personnel during these
441
00:24:05,733 --> 00:24:08,933
high contact resident care
activities.
442
00:24:08,933 --> 00:24:10,033
443
00:24:10,033 --> 00:24:15,033
And again these results that we
have on the slide showing on the
444
00:24:15,033 --> 00:24:20,333
bar indicate that EBP was an
evidence based approach for
445
00:24:20,333 --> 00:24:25,500
preventing the transmission of
MDROs and additional related
446
00:24:25,500 --> 00:24:31,000
studies are ongoing right now to
continue to support our ongoing
447
00:24:31,000 --> 00:24:36,233
understanding of the most of the
most effective approaches to
448
00:24:36,233 --> 00:24:40,233
preventing MDRO transmission in
nursing homes.
449
00:24:40,233 --> 00:24:40,700
450
00:24:40,700 --> 00:24:46,600
So again, nursing homes have
successfully identified who met
451
00:24:46,600 --> 00:24:53,666
EBP, as well as, successfully been
able to have adherence to gown
452
00:24:53,666 --> 00:24:57,466
and glove use within their
different facilities.
453
00:24:57,466 --> 00:24:59,233
454
00:24:59,233 --> 00:25:05,666
And so we have had our partners
share the possibility of having
455
00:25:05,666 --> 00:25:09,200
EBP implemented and the
successes that our partners have
456
00:25:09,200 --> 00:25:14,466
found as well as challenges that
our partners have been able to
457
00:25:14,466 --> 00:25:18,733
identify with implemented EBP
at our nursing homes.
458
00:25:18,733 --> 00:25:19,233
459
00:25:19,233 --> 00:25:23,833
So with that said, I will hand
over to Heather to talk about
460
00:25:23,833 --> 00:25:29,500
why we need EBP as part of the
MDRO prevention strategy.
461
00:25:29,500 --> 00:25:30,033
462
00:25:30,033 --> 00:25:30,733
Thank you, Heather.
463
00:25:30,733 --> 00:25:32,466
464
00:25:32,466 --> 00:25:34,133
Thank you so much, Bola.
465
00:25:34,133 --> 00:25:34,600
466
00:25:34,600 --> 00:25:37,066
I'm now going to discuss why it
is needed.
467
00:25:37,066 --> 00:25:41,033
Why do we need enhanced barrier
precautions as part of an MDRO
468
00:25:41,033 --> 00:25:42,300
prevention strategy?
469
00:25:42,300 --> 00:25:44,066
470
00:25:44,066 --> 00:25:48,433
First, nursing home residents
are at the highest risk and
471
00:25:48,433 --> 00:25:53,433
higher risks for not only having
but getting MDRO colonization or
472
00:25:53,433 --> 00:25:54,200
infection.
473
00:25:54,200 --> 00:25:54,833
474
00:25:54,833 --> 00:25:59,066
A majority of people who live in
nursing homes are older, and as
475
00:25:59,066 --> 00:26:03,266
a person ages, the body is less
able to fight infection as they
476
00:26:03,266 --> 00:26:05,866
would have been when they were
younger.
477
00:26:05,866 --> 00:26:06,666
478
00:26:06,666 --> 00:26:11,466
Most have multiple comorbid
conditions such as high blood
479
00:26:11,466 --> 00:26:16,166
pressure, chronic kidney
disease, or chronic respiratory
480
00:26:16,166 --> 00:26:17,066
conditions.
481
00:26:17,066 --> 00:26:17,800
482
00:26:17,800 --> 00:26:21,733
Nursing home residents also
depends on many of the staff
483
00:26:21,733 --> 00:26:26,133
members to help them with caring
for themselves, whether through
484
00:26:26,133 --> 00:26:28,666
physical or cognitive
limitations.
485
00:26:28,666 --> 00:26:29,300
486
00:26:29,300 --> 00:26:34,333
There is also a high social
context within nursing homes and
487
00:26:34,333 --> 00:26:38,866
multiple interactions occur
between both residents and
488
00:26:38,866 --> 00:26:39,333
staff.
489
00:26:39,333 --> 00:26:42,266
490
00:26:42,266 --> 00:26:46,300
Other higher risk factors that
affect the likelihood of MDRO
491
00:26:46,300 --> 00:26:50,166
spread is that a lot of the
residents have had a recent or a
492
00:26:50,166 --> 00:26:54,400
long hospital stay, they have
wounds and in dwelling medical
493
00:26:54,400 --> 00:26:54,933
devices.
494
00:26:54,933 --> 00:26:55,700
495
00:26:55,700 --> 00:26:59,766
A majority of nursing homes in
the United States continue to
496
00:26:59,766 --> 00:27:03,933
have multi resident rooms with
up to four residents together in
497
00:27:03,933 --> 00:27:04,633
one room.
498
00:27:04,633 --> 00:27:05,300
499
00:27:05,300 --> 00:27:09,233
There is also a continued
overuse of antibiotics in our
500
00:27:09,233 --> 00:27:13,566
nursing home residents which all
can place them at a higher risk
501
00:27:13,566 --> 00:27:15,233
of acquiring a MDRO.
502
00:27:15,233 --> 00:27:17,833
503
00:27:17,833 --> 00:27:22,033
So how can you be successful in
implementing enhanced barrier
504
00:27:22,033 --> 00:27:22,866
precautions?
505
00:27:22,866 --> 00:27:25,466
506
00:27:25,466 --> 00:27:28,933
It starts with robust and
foundational prevention
507
00:27:28,933 --> 00:27:33,800
strategies along with enhanced
barrier precautions from cleaning
508
00:27:33,800 --> 00:27:37,366
your hands to environmental
cleaning and disinfection,
509
00:27:37,366 --> 00:27:41,100
auditing practices and good
communication.
510
00:27:41,100 --> 00:27:43,533
511
00:27:43,533 --> 00:27:47,500
First, very foundational
information, but also very
512
00:27:47,500 --> 00:27:51,900
important is to emphasize
cleaning your hands, especially
513
00:27:51,900 --> 00:27:56,633
before and after any care with a
resident or patient or after
514
00:27:56,633 --> 00:28:00,500
using or touching equipment in
their environments.
515
00:28:00,500 --> 00:28:01,333
516
00:28:01,333 --> 00:28:05,333
Alcohol based hand sanitizers
continue to be the preferred
517
00:28:05,333 --> 00:28:10,000
method for cleaning your hands
when they are not visibly dirty
518
00:28:10,000 --> 00:28:12,800
and when your hands are visibly
dirty,
519
00:28:12,800 --> 00:28:13,033
520
00:28:13,033 --> 00:28:17,266
clean your hands with soap and
water and make sure that staff
521
00:28:17,266 --> 00:28:21,233
has easy accessibility to the
products they need to clean
522
00:28:21,233 --> 00:28:23,033
their hands appropriately.
523
00:28:23,033 --> 00:28:25,733
524
00:28:25,733 --> 00:28:28,033
Next up is cleaning and
disinfection.
525
00:28:28,033 --> 00:28:28,666
526
00:28:28,666 --> 00:28:32,400
Although many times seen as a
primary duty of Environmental
527
00:28:32,400 --> 00:28:36,766
Services staff members, cleaning
and disinfection is important
528
00:28:36,766 --> 00:28:38,666
for everyone to take part in.
529
00:28:38,666 --> 00:28:39,300
530
00:28:39,300 --> 00:28:43,700
Make sure high touch surfaces
are cleaned and disinfected at
531
00:28:43,700 --> 00:28:48,066
least daily and reusable
equipment must be cleaned and
532
00:28:48,066 --> 00:28:51,266
disinfected after each and every
use.
533
00:28:51,266 --> 00:28:52,066
534
00:28:52,066 --> 00:28:55,700
Work with others in your
community or facility to reduce
535
00:28:55,700 --> 00:28:58,466
the number of cleaning and
disinfection products you were
536
00:28:58,466 --> 00:29:02,900
using while also ensuring the
most appropriate hospital grade
537
00:29:02,900 --> 00:29:08,866
products are being used and
develop, maintain and use a who
538
00:29:08,866 --> 00:29:13,266
cleans what list so that
everyone on the team knows who
539
00:29:13,266 --> 00:29:15,500
is responsible for which items.
540
00:29:15,500 --> 00:29:18,233
541
00:29:18,233 --> 00:29:20,600
Next is a brief discussion about
auditing.
542
00:29:20,600 --> 00:29:21,266
543
00:29:21,266 --> 00:29:24,366
Auditing is your way of knowing
if the education you have
544
00:29:24,366 --> 00:29:27,800
provided to staff is being
implemented and done
545
00:29:27,800 --> 00:29:28,666
appropriately.
546
00:29:28,666 --> 00:29:29,233
547
00:29:29,233 --> 00:29:32,733
This should happen with all
aspects of infection prevention
548
00:29:32,733 --> 00:29:36,700
and control and include hand
hygiene audits.
549
00:29:36,700 --> 00:29:37,233
550
00:29:37,233 --> 00:29:41,533
How well are PPE being taken off
and put on?
551
00:29:41,533 --> 00:29:42,066
552
00:29:42,066 --> 00:29:46,200
Also looking at the cleaning and
disinfection practices and not
553
00:29:46,200 --> 00:29:50,666
only at those high touch
locations but also daily and
554
00:29:50,666 --> 00:29:52,200
terminal room cleans.
555
00:29:52,200 --> 00:29:52,800
556
00:29:52,800 --> 00:29:56,900
And audit your communication
practices of the staff members
557
00:29:56,900 --> 00:30:01,433
and as important is to share the
feedback with your staff so they
558
00:30:01,433 --> 00:30:05,000
know if there are opportunities
for improvement and
559
00:30:05,000 --> 00:30:08,433
acknowledging when challenges
have been overcome.
560
00:30:08,433 --> 00:30:11,633
561
00:30:11,633 --> 00:30:15,566
Communication is the final piece
of the prevention strategies I
562
00:30:15,566 --> 00:30:16,666
wanted to discuss.
563
00:30:16,666 --> 00:30:17,233
564
00:30:17,233 --> 00:30:21,933
Communication should not only
occur within the units of your
565
00:30:21,933 --> 00:30:25,833
facility but also with outside
partners.
566
00:30:25,833 --> 00:30:26,333
567
00:30:26,333 --> 00:30:30,433
Find and use a communication
tool that works for everyone
568
00:30:30,433 --> 00:30:34,233
across the community and make
sure pertinent information is
569
00:30:34,233 --> 00:30:36,833
shared as we are all connected.
570
00:30:36,833 --> 00:30:41,133
571
00:30:41,133 --> 00:30:44,566
Here are a few more tips to help
you with the initial
572
00:30:44,566 --> 00:30:49,000
implementation of EBP in your
facility or facilities.
573
00:30:49,000 --> 00:30:49,900
574
00:30:49,900 --> 00:30:54,033
Provide initial and ongoing
education to everyone who comes
575
00:30:54,033 --> 00:30:58,466
into, works in, or lives in your
community or facility.
576
00:30:58,466 --> 00:30:58,933
577
00:30:58,933 --> 00:31:02,000
Include all staff and all
shifts.
578
00:31:02,000 --> 00:31:02,533
579
00:31:02,533 --> 00:31:05,400
Don't forget to provide
education to the overnight
580
00:31:05,400 --> 00:31:07,400
shifts and the weekend staff.
581
00:31:07,400 --> 00:31:08,400
582
00:31:08,400 --> 00:31:12,066
Create a robust rollout plan and
use the tools that have been
583
00:31:12,066 --> 00:31:12,833
developed.
584
00:31:12,833 --> 00:31:13,200
585
00:31:13,200 --> 00:31:14,800
Don't reinvent the wheel.
586
00:31:14,800 --> 00:31:15,466
587
00:31:15,466 --> 00:31:18,400
Many of the tools can be
customized so you can tailor
588
00:31:18,400 --> 00:31:20,433
them to your unique community.
589
00:31:20,433 --> 00:31:21,133
590
00:31:21,133 --> 00:31:25,766
Start by using the CDC Pre
Implementation tool and make
591
00:31:25,766 --> 00:31:31,000
sure to 1st identify a method
which residents need EBP
592
00:31:31,000 --> 00:31:35,700
initiated and then how best to
maintain this record.
593
00:31:35,700 --> 00:31:40,466
594
00:31:40,466 --> 00:31:44,733
Now I want to show you just one
example of what can happen when
595
00:31:44,733 --> 00:31:48,133
any one of these prevention
strategies are missed.
596
00:31:48,133 --> 00:31:50,000
597
00:31:50,000 --> 00:31:56,600
You have an acute care hospital
which has a known MDRO outbreak
598
00:31:56,600 --> 00:32:01,266
and patient A and patient B
arrive for care.
599
00:32:01,266 --> 00:32:04,600
600
00:32:04,600 --> 00:32:12,700
During patient A stay, they
acquire a MDRO, then patient A
601
00:32:12,700 --> 00:32:16,733
and patient B transfer out to a
long term acute care hospital
602
00:32:16,733 --> 00:32:18,466
for further care.
603
00:32:18,466 --> 00:32:19,233
604
00:32:19,233 --> 00:32:24,500
Patient A brings that MDRO along
with them. Well through poor
605
00:32:24,500 --> 00:32:26,300
preventive practices.
606
00:32:26,300 --> 00:32:26,400
607
00:32:26,400 --> 00:32:32,600
Patient B now also acquires or
gets the MDRO. Well,
608
00:32:32,600 --> 00:32:37,833
after a little bit of time they
part ways and patient A goes to
609
00:32:37,833 --> 00:32:43,200
a skilled nursing facility or
SNF 1 and takes the MDRO
610
00:32:43,200 --> 00:32:44,000
along with them.
611
00:32:44,000 --> 00:32:45,900
612
00:32:45,900 --> 00:32:50,433
Patient A or resident now
Resident A meets Resident C and
613
00:32:50,433 --> 00:32:56,966
Resident D through bad practices
and not following appropriate
614
00:32:56,966 --> 00:32:59,233
and adequate prevention
practices,
615
00:32:59,233 --> 00:32:59,533
616
00:32:59,533 --> 00:33:05,333
now Resident C and Resident D
also have acquired or gotten the
617
00:33:05,333 --> 00:33:06,266
MDRO.
618
00:33:06,266 --> 00:33:08,400
619
00:33:08,400 --> 00:33:16,433
And let's not forget Resident B.
Resident B went to SNF 2 and
620
00:33:16,433 --> 00:33:20,533
took the MDRO with them as well.
621
00:33:20,533 --> 00:33:21,233
622
00:33:21,233 --> 00:33:25,766
So then Resident B meets
Resident E and Resident F in
623
00:33:25,766 --> 00:33:29,866
that SNF 2. Through poor
prevention practices,
624
00:33:29,866 --> 00:33:35,066
once again, Resident E and
Resident F acquire or get the
625
00:33:35,066 --> 00:33:36,633
MDRO as well.
626
00:33:36,633 --> 00:33:37,600
627
00:33:37,600 --> 00:33:41,633
So due to prevention practices
not being followed, such as a
628
00:33:41,633 --> 00:33:46,733
lapse and communicating MDRO
status, perhaps staff weren't
629
00:33:46,733 --> 00:33:49,966
cleaning their hands after
providing care to the patient or
630
00:33:49,966 --> 00:33:53,233
residents once they got to the
SNF.
631
00:33:53,233 --> 00:33:57,266
Maybe they didn't put them on
enhanced barrier precautions and
632
00:33:57,266 --> 00:34:02,133
they had an indwelling medical
device that necessitated them
633
00:34:02,133 --> 00:34:03,033
being on it.
634
00:34:03,033 --> 00:34:04,000
635
00:34:04,000 --> 00:34:08,766
Someone didn't clean and
disinfect as was required or
636
00:34:08,766 --> 00:34:12,733
there's an absence of auditing
in any one of these locations.
637
00:34:12,733 --> 00:34:13,800
638
00:34:13,800 --> 00:34:18,333
So what happened was that what
was only one MDRO colonization
639
00:34:18,333 --> 00:34:24,000
or infection at the acute care
hospital has now become six MDRO
640
00:34:24,000 --> 00:34:28,733
colonizations or infections
across two separate long term
641
00:34:28,733 --> 00:34:30,033
care facilities.
642
00:34:30,033 --> 00:34:30,733
643
00:34:30,733 --> 00:34:35,733
And as I shared, this is only
one brief example of how MDROs
644
00:34:35,733 --> 00:34:42,400
can spread across healthcare
communities. Which brings me to
645
00:34:42,400 --> 00:34:47,300
my final slide and that is to
emphasize enhanced barrier
646
00:34:47,300 --> 00:34:51,533
precautions being a method to
balance safety of the residents
647
00:34:51,533 --> 00:34:54,133
with maintaining the residents
quality of life.
648
00:34:54,133 --> 00:34:54,733
649
00:34:54,733 --> 00:34:59,066
We know MDROs are common in
nursing homes and the MDRO
650
00:34:59,066 --> 00:35:04,266
colonization can lead to serious
infections and even death in our
651
00:35:04,266 --> 00:35:05,066
residents.
652
00:35:05,066 --> 00:35:05,933
653
00:35:05,933 --> 00:35:10,700
Implementing strategies such as
enhanced barrier precautions can
654
00:35:10,700 --> 00:35:15,000
prevent the spread of MDROs
while considering the unique
655
00:35:15,000 --> 00:35:18,500
aspects of nursing home care and
socialization.
656
00:35:18,500 --> 00:35:19,233
657
00:35:19,233 --> 00:35:23,066
While in other healthcare
settings, the answer is to use
658
00:35:23,066 --> 00:35:26,933
contact precautions for MDRO
infection or colonization.
659
00:35:26,933 --> 00:35:27,466
660
00:35:27,466 --> 00:35:31,000
A nursing home is not an
appropriate setting for long
661
00:35:31,000 --> 00:35:35,733
term prevention of MDROs with
contact precautions as it would
662
00:35:35,733 --> 00:35:39,333
see residents not being able to
maintain a good quality of life
663
00:35:39,333 --> 00:35:43,033
because they would be restricted
to the rooms except for
664
00:35:43,033 --> 00:35:46,866
medically necessary care, as
well as being restricted from
665
00:35:46,866 --> 00:35:49,933
being able to participate in
group activities.
666
00:35:49,933 --> 00:35:50,833
667
00:35:50,833 --> 00:35:54,833
Enhanced Barrier precautions is
a prevention strategy that
668
00:35:54,833 --> 00:35:57,000
balances each of these together.
669
00:35:57,000 --> 00:35:57,300
670
00:35:57,300 --> 00:36:01,766
Prevention of MDRO spread,
maintaining resident safety and
671
00:36:01,766 --> 00:36:04,800
improving a resident's quality
of life.
672
00:36:04,800 --> 00:36:06,800
673
00:36:06,800 --> 00:36:11,233
As we shared previously, the
slides will be made available
674
00:36:11,233 --> 00:36:13,666
after our webinar and town hall.
675
00:36:13,666 --> 00:36:14,033
676
00:36:14,033 --> 00:36:18,066
And these are a few of the links
updated since our recent
677
00:36:18,066 --> 00:36:20,900
Clean Slate CDC.gov updates.
678
00:36:20,900 --> 00:36:21,266
679
00:36:21,266 --> 00:36:24,700
And these provide some of our
educational videos that are
680
00:36:24,700 --> 00:36:26,100
available on this slide.
681
00:36:26,100 --> 00:36:26,866
682
00:36:26,866 --> 00:36:30,000
And then these are enhanced
barrier precaution tools that
683
00:36:30,000 --> 00:36:35,266
can help you with implementation
as well as letters that you are
684
00:36:35,266 --> 00:36:39,766
able to customize for residents,
families, staff and nursing home
685
00:36:39,766 --> 00:36:40,500
leadership.
686
00:36:40,500 --> 00:36:41,933
687
00:36:41,933 --> 00:36:46,600
We've also developed posters and
a pocket guide that can help you
688
00:36:46,600 --> 00:36:50,133
with the staff development and
ongoing education.
689
00:36:50,133 --> 00:36:52,700
690
00:36:52,700 --> 00:36:56,300
I will now turn it back to Kara
who will moderate for any
691
00:36:56,300 --> 00:36:56,900
questions.
692
00:36:56,900 --> 00:36:57,133
693
00:36:57,133 --> 00:36:57,700
Thank you.
694
00:36:57,700 --> 00:37:00,133
695
00:37:00,133 --> 00:37:01,200
Thank you so much.
696
00:37:01,200 --> 00:37:04,600
I want to, I want to give a
special thank you to Doctor
697
00:37:04,600 --> 00:37:08,900
Ogundimu and Doctor Jones for
walking us through this webinar.
698
00:37:08,900 --> 00:37:09,266
699
00:37:09,266 --> 00:37:13,000
I have been taking note of the
questions that are coming in.
700
00:37:13,000 --> 00:37:13,233
701
00:37:13,233 --> 00:37:16,633
We will do our best to try to
get to as many of those as
702
00:37:16,633 --> 00:37:17,200
possible.
703
00:37:17,200 --> 00:37:17,700
704
00:37:17,700 --> 00:37:22,333
I may combine some of them and
try to give an answer that will
705
00:37:22,333 --> 00:37:26,800
hopefully help with the related
questions that we are seeing
706
00:37:26,800 --> 00:37:27,533
coming in.
707
00:37:27,533 --> 00:37:28,600
708
00:37:28,600 --> 00:37:36,366
So to start, I think we have had
a couple of questions that have
709
00:37:36,366 --> 00:37:39,233
been specific to wounds.
710
00:37:39,233 --> 00:37:43,300
So I think let's go ahead and
start with clarifying what
711
00:37:43,300 --> 00:37:46,966
wounds would be an indication
for enhanced barrier
712
00:37:46,966 --> 00:37:47,833
precautions.
713
00:37:47,833 --> 00:37:49,733
714
00:37:49,733 --> 00:37:50,666
Thanks, Kara.
715
00:37:50,666 --> 00:37:53,000
And that's a pretty great
question.
716
00:37:53,000 --> 00:37:53,866
717
00:37:53,866 --> 00:37:59,400
So the guide, our EBP
guidance describes that all
718
00:37:59,400 --> 00:38:05,766
residents with rooms would meet
the enhanced barrier precautions
719
00:38:05,766 --> 00:38:06,700
guidance.
720
00:38:06,700 --> 00:38:08,133
721
00:38:08,133 --> 00:38:14,566
However, the intent again of our
EBP guidance is to focus on
722
00:38:14,566 --> 00:38:20,766
residents that have a higher
risk of acquiring MDRO over a
723
00:38:20,766 --> 00:38:25,700
long period of time, so not just
hours, right.
724
00:38:25,700 --> 00:38:26,100
725
00:38:26,100 --> 00:38:31,066
And so within the enhanced barrier
precautions, frequently asked
726
00:38:31,066 --> 00:38:37,766
questions or FAQs, we actually
expand more on describing the
727
00:38:37,766 --> 00:38:42,133
focus on residents with chronic
wounds and not the short term
728
00:38:42,133 --> 00:38:47,266
wounds like the band-aids, quote
and quote ones, as I noted
729
00:38:47,266 --> 00:38:47,933
earlier.
730
00:38:47,933 --> 00:38:48,133
731
00:38:48,133 --> 00:38:52,900
So it's more chronic wounds that
include your pressure ulcers as
732
00:38:52,900 --> 00:38:57,933
well as diabetic foot ulcers and
chronic venous stasis ulcers.
733
00:38:57,933 --> 00:38:59,200
734
00:38:59,200 --> 00:38:59,666
Thank you.
735
00:38:59,666 --> 00:38:59,833
736
00:38:59,833 --> 00:39:01,433
So thank you.
737
00:39:01,433 --> 00:39:05,066
So the focus being on chronic
longer lasting wounds and then
738
00:39:05,066 --> 00:39:08,900
you started to mention are there
wounds that are not considered
739
00:39:08,900 --> 00:39:10,600
to be an indication for EBP?
740
00:39:10,600 --> 00:39:11,466
741
00:39:11,466 --> 00:39:12,600
Yeah, thanks, Kara.
742
00:39:12,600 --> 00:39:17,633
So yeah, your shorter lasting
wounds as I indicated earlier,
743
00:39:17,633 --> 00:39:22,766
the band-aid wounds or the skin
grades or skin tears that are
744
00:39:22,766 --> 00:39:27,433
again like cover like with the
small dressing or shorter period
745
00:39:27,433 --> 00:39:33,233
of time or anything similar
in terms of the dressing would
746
00:39:33,233 --> 00:39:35,633
not be an indication for EBP.
747
00:39:35,633 --> 00:39:38,466
Again, it's a shorter time kind
of route.
748
00:39:38,466 --> 00:39:39,800
749
00:39:39,800 --> 00:39:45,966
And so for we did actually have
fielded questions from different
750
00:39:45,966 --> 00:39:51,466
facilities as well as HAI
programs about healing post op
751
00:39:51,466 --> 00:39:57,633
surgical wounds and that
specifically healing post op
752
00:39:57,633 --> 00:40:01,500
surgical wounds would not be an
indication for EBP.
753
00:40:01,500 --> 00:40:02,466
754
00:40:02,466 --> 00:40:02,900
Thank you.
755
00:40:02,900 --> 00:40:06,133
And that came up that has come
up a few times in the, the
756
00:40:06,133 --> 00:40:08,266
Q&A on the webinar today.
757
00:40:08,266 --> 00:40:08,600
758
00:40:08,600 --> 00:40:12,233
So, you know, while there isn't
a definition for the exact
759
00:40:12,233 --> 00:40:16,266
amount of time that a wound must
be present to become colonized,
760
00:40:16,266 --> 00:40:19,866
we recognize that the longer a
wound is present, the more
761
00:40:19,866 --> 00:40:23,233
concern we have that these
wounds may become colonized with
762
00:40:23,233 --> 00:40:24,066
an MDRO.
763
00:40:24,066 --> 00:40:24,433
764
00:40:24,433 --> 00:40:28,100
And so in situations where
underlying medical conditions
765
00:40:28,100 --> 00:40:31,800
lead to chronic poorly healing
wounds, our concern level
766
00:40:31,800 --> 00:40:35,433
increases that those may become
colonized with an MDRO.
767
00:40:35,433 --> 00:40:36,233
768
00:40:36,233 --> 00:40:39,300
So I do also because again, a
few questions have come up.
769
00:40:39,300 --> 00:40:39,433
770
00:40:39,433 --> 00:40:41,433
I think this is related to
wounds.
771
00:40:41,433 --> 00:40:41,666
772
00:40:41,666 --> 00:40:45,800
There are a few questions about
ostomies specifically. Do we
773
00:40:45,800 --> 00:40:48,066
are those considered to be
wounds?
774
00:40:48,066 --> 00:40:50,000
775
00:40:50,000 --> 00:40:52,466
Thanks for that excellent
question, Kara.
776
00:40:52,466 --> 00:40:52,700
777
00:40:52,700 --> 00:40:54,500
No ostomies.
778
00:40:54,500 --> 00:40:54,700
779
00:40:54,700 --> 00:40:57,733
And when I talk about ostomies,
I'm referring to like
780
00:40:57,733 --> 00:41:00,200
colostomies and ileostomies.
781
00:41:00,200 --> 00:41:03,566
These are not considered to be
wounds for enhanced barrier
782
00:41:03,566 --> 00:41:04,266
precautions.
783
00:41:04,266 --> 00:41:04,733
784
00:41:04,733 --> 00:41:08,133
And to help clarify this
commonly asked question, we have
785
00:41:08,133 --> 00:41:12,200
also updated our enhanced
barrier precautions frequently
786
00:41:12,200 --> 00:41:15,866
asked questions page to
specifically address ostomies so
787
00:41:15,866 --> 00:41:20,000
that you'll have a way to refer
back in case you have questions
788
00:41:20,000 --> 00:41:21,300
that are brought up.
789
00:41:21,300 --> 00:41:24,533
790
00:41:24,533 --> 00:41:31,600
Now, ostomies are not considered
to be wounds, but for EBP
791
00:41:31,600 --> 00:41:35,800
purposes, but if they have an
indwelling medical device, so
792
00:41:35,800 --> 00:41:39,833
like if you're thinking about a
tracheostomy tube or a
793
00:41:39,833 --> 00:41:44,433
percutaneous nephrostomy tube,
those would be an indication for
794
00:41:44,433 --> 00:41:48,866
EBP because there's now a
component that's communicating
795
00:41:48,866 --> 00:41:52,900
internally and externally, which
places them at a higher risk of
796
00:41:52,900 --> 00:41:56,233
getting an MDRO or even
acquiring one.
797
00:41:56,233 --> 00:41:58,033
798
00:41:58,033 --> 00:41:58,833
Thank you, Heather.
799
00:41:58,833 --> 00:42:00,400
800
00:42:00,400 --> 00:42:04,633
One of the other common, one of
the other common questions I've
801
00:42:04,633 --> 00:42:09,366
seen about throughout the chat
has been asking about physical
802
00:42:09,366 --> 00:42:15,166
therapy, asking about therapy,
you know, in a therapy gym there
803
00:42:15,166 --> 00:42:18,100
there have been numerous
questions that have brought up
804
00:42:18,100 --> 00:42:20,600
therapy and wanting us to
clarify a little bit more here.
805
00:42:20,600 --> 00:42:21,233
806
00:42:21,233 --> 00:42:24,500
And we definitely recognize that
physical therapy encompasses a
807
00:42:24,500 --> 00:42:28,166
wide range and not just physical
therapy, occupational therapy,
808
00:42:28,166 --> 00:42:29,200
therapy activities.
809
00:42:29,200 --> 00:42:33,000
They there are a wide range of
activities and they are not
810
00:42:33,000 --> 00:42:37,100
specifically called out as high
contact resident care activity.
811
00:42:37,100 --> 00:42:37,333
812
00:42:37,333 --> 00:42:42,066
So can you can, can you talk a
little bit about whether
813
00:42:42,066 --> 00:42:45,400
physical therapy or therapy is
considered to be high contact?
814
00:42:45,400 --> 00:42:47,833
Should therapists be using PPE?
815
00:42:47,833 --> 00:42:49,800
816
00:42:49,800 --> 00:42:50,100
Yeah.
817
00:42:50,100 --> 00:42:50,200
818
00:42:50,200 --> 00:42:52,066
Thank you so much, Kara.
819
00:42:52,066 --> 00:42:57,900
So depending on the activity,
therapy may be considered a high
820
00:42:57,900 --> 00:43:00,800
contact resident care activity.
821
00:43:00,800 --> 00:43:02,033
822
00:43:02,033 --> 00:43:07,866
And again, we see therapists
should use gown and gloves when
823
00:43:07,866 --> 00:43:13,900
when working with residents on
EBP and the therapy gym that's
824
00:43:13,900 --> 00:43:20,466
ideal or in the resident鈥檚 room if
they anticipate having that
825
00:43:20,466 --> 00:43:25,766
prolonged to those body contacts
where transmission of MDROs
826
00:43:25,766 --> 00:43:30,200
to the therapist clothes is
certainly possible.
827
00:43:30,200 --> 00:43:36,166
And so as a follow up to that,
what if the therapy can't be
828
00:43:36,166 --> 00:43:40,233
performed in the therapy gym or
in the resident鈥檚 room?
829
00:43:40,233 --> 00:43:40,433
830
00:43:40,433 --> 00:43:44,000
Or as some examples in the chat
have shared, what if the
831
00:43:44,000 --> 00:43:47,566
resident needs assistance
walking from their room to the
832
00:43:47,566 --> 00:43:49,500
therapy gym or in the hallways?
833
00:43:49,500 --> 00:43:50,266
834
00:43:50,266 --> 00:43:52,666
Is it OK to use PPE in the
hallways?
835
00:43:52,666 --> 00:43:53,933
836
00:43:53,933 --> 00:43:56,000
Yeah, that's a great follow up
question.
837
00:43:56,000 --> 00:44:01,666
So EBP is it really should not
limit a resident's ability to
838
00:44:01,666 --> 00:44:06,900
continue their medical therapy
that is critical, right?
839
00:44:06,900 --> 00:44:07,500
840
00:44:07,500 --> 00:44:12,633
And so while the use of gowns
and gloves is generally
841
00:44:12,633 --> 00:44:18,566
discouraged in the hallways and
other common areas, there may be
842
00:44:18,566 --> 00:44:23,666
individual circumstances like
therapy that has to occur
843
00:44:23,666 --> 00:44:29,066
outside the resident鈥檚 room or
outside the therapy gym that
844
00:44:29,066 --> 00:44:34,733
would prompt an evaluation for
the need of PPE outside of the
845
00:44:34,733 --> 00:44:36,200
room or the gym.
846
00:44:36,200 --> 00:44:36,700
847
00:44:36,700 --> 00:44:41,100
Really depending on the level of
assistance or close contacts
848
00:44:41,100 --> 00:44:45,533
that the therapist or anybody
helping out with therapy will be
849
00:44:45,533 --> 00:44:47,300
happening with the residents.
850
00:44:47,300 --> 00:44:51,133
851
00:44:51,133 --> 00:44:55,133
And I also wanted to add a
comment here that we understand
852
00:44:55,133 --> 00:44:59,466
and we know that there is a lot
of gray area when we talk about
853
00:44:59,466 --> 00:45:03,633
these situations and when it
comes to infection prevention in
854
00:45:03,633 --> 00:45:07,700
general and not just with the
practices of enhanced barrier
855
00:45:07,700 --> 00:45:08,500
precautions.
856
00:45:08,500 --> 00:45:09,066
857
00:45:09,066 --> 00:45:12,600
Because we understand that even
the most seasoned infection
858
00:45:12,600 --> 00:45:15,966
preventionists are going to be
faced with new different
859
00:45:15,966 --> 00:45:20,133
situations and you will need to
evaluate those situations based
860
00:45:20,133 --> 00:45:24,300
on your expertise as they arise
and then make the best
861
00:45:24,300 --> 00:45:28,333
determinations based on best
practices for both the residents
862
00:45:28,333 --> 00:45:30,533
and the healthcare worker
safety.
863
00:45:30,533 --> 00:45:31,900
864
00:45:31,900 --> 00:45:32,700
Thank you both.
865
00:45:32,700 --> 00:45:33,600
866
00:45:33,600 --> 00:45:36,733
I want to shift the topic a
little bit to talk about
867
00:45:36,733 --> 00:45:40,966
midlines because there are
multiple questions that have
868
00:45:40,966 --> 00:45:45,533
come in during the webinar
specific to midlines or midline
869
00:45:45,533 --> 00:45:50,966
catheters and asking for more
explanation in terms of are
870
00:45:50,966 --> 00:45:53,466
these considered to be
indwelling medical devices for
871
00:45:53,466 --> 00:45:56,733
the purposes of enhanced barrier
precautions?
872
00:45:56,733 --> 00:46:00,133
873
00:46:00,133 --> 00:46:02,633
Yeah, thank you so much for
another great question.
874
00:46:02,633 --> 00:46:09,366
So yes, midlines in addition to
central venus catheters, so your
875
00:46:09,366 --> 00:46:16,966
CVCs that includes your ports or
PICC lines are considered
876
00:46:16,966 --> 00:46:21,100
indwelling medical devices for
the purposes of EBP.
877
00:46:21,100 --> 00:46:21,733
878
00:46:21,733 --> 00:46:26,233
Yes. And thank you, Bola, can you
expand upon that a little bit?
879
00:46:26,233 --> 00:46:26,400
880
00:46:26,400 --> 00:46:31,000
Some of the questions have asked
since peripheral IVs are not
881
00:46:31,000 --> 00:46:37,200
included as indwelling medical
devices for EBP and you know,
882
00:46:37,200 --> 00:46:39,966
can you share a little bit
more about why midlines are
883
00:46:39,966 --> 00:46:42,333
considered an indwelling device?
884
00:46:42,333 --> 00:46:43,133
885
00:46:43,133 --> 00:46:44,333
Yeah, great follow up.
886
00:46:44,333 --> 00:46:50,166
So more importantly, residents
who have midline catheters as
887
00:46:50,166 --> 00:46:54,566
part of their medical therapy,
often complex, right, tend to be
888
00:46:54,566 --> 00:46:58,833
residents with additional risk
factors for MDRO
889
00:46:58,833 --> 00:46:59,900
colonization.
890
00:46:59,900 --> 00:47:00,300
891
00:47:00,300 --> 00:47:06,700
So similar to central venous
catheters, PICC supports these
892
00:47:06,700 --> 00:47:11,366
midlines may remain in place for
an extended period of time,
893
00:47:11,366 --> 00:47:16,866
again longer period of time,
often up to four weeks or more
894
00:47:16,866 --> 00:47:22,666
and thereby increasing
the risk of an infection or MDRO
895
00:47:22,666 --> 00:47:23,800
acquisition.
896
00:47:23,800 --> 00:47:25,466
897
00:47:25,466 --> 00:47:26,033
Thank you.
898
00:47:26,033 --> 00:47:26,233
899
00:47:26,233 --> 00:47:26,866
Thank you, Bola.
900
00:47:26,866 --> 00:47:28,066
901
00:47:28,066 --> 00:47:32,800
I'm seeing numerous questions
asking for us to expand a little
902
00:47:32,800 --> 00:47:36,800
bit more on the brief
contact that was mentioned
903
00:47:36,800 --> 00:47:38,233
during the webinar.
904
00:47:38,233 --> 00:47:39,200
905
00:47:39,200 --> 00:47:43,733
So are can you expand or one of
you able to expand a little bit
906
00:47:43,733 --> 00:47:48,233
more on what those situations
might be, you know, particularly
907
00:47:48,233 --> 00:47:53,466
inside of a resident鈥檚 room who's
on EBP where limited enough
908
00:47:53,466 --> 00:47:56,800
contact occurs between the
resident and nursing home staff
909
00:47:56,800 --> 00:47:59,066
that PPE might not be indicated?
910
00:47:59,066 --> 00:48:02,133
911
00:48:02,133 --> 00:48:03,700
Absolutely, Kara, thank you.
912
00:48:03,700 --> 00:48:04,866
913
00:48:04,866 --> 00:48:06,933
So we've been asked about
situations.
914
00:48:06,933 --> 00:48:08,133
915
00:48:08,133 --> 00:48:12,466
One example is like going into
the resident鈥檚 room and helping
916
00:48:12,466 --> 00:48:18,733
them put on a sweater or going
in to just do a minimal transfer
917
00:48:18,733 --> 00:48:21,733
and it's brief contact that
occurs.
918
00:48:21,733 --> 00:48:26,833
Or even if you're individually
going in to brush someone's
919
00:48:26,833 --> 00:48:27,266
hair.
920
00:48:27,266 --> 00:48:27,933
921
00:48:27,933 --> 00:48:31,466
These are examples of activities
that Bola shared previously.
922
00:48:31,466 --> 00:48:35,533
They're constantly
bundled together as part of
923
00:48:35,533 --> 00:48:40,266
morning or evening care rather
than occurring as those multiple
924
00:48:40,266 --> 00:48:43,400
isolated interactions throughout
the day.
925
00:48:43,400 --> 00:48:44,100
926
00:48:44,100 --> 00:48:48,500
When bundled together, it would
be an indication to wear a gown
927
00:48:48,500 --> 00:48:52,233
and gloves because you're having
that prolonged contact care with
928
00:48:52,233 --> 00:48:55,300
the residents while you're
bundling it together.
929
00:48:55,300 --> 00:48:56,633
930
00:48:56,633 --> 00:49:01,533
But if you're in there for an
isolated activity, you're having
931
00:49:01,533 --> 00:49:06,200
a short brief interaction
contact with the resident,
932
00:49:06,200 --> 00:49:06,666
933
00:49:06,666 --> 00:49:10,233
this would not generally
necessitate the need for using
934
00:49:10,233 --> 00:49:11,266
gown and gloves.
935
00:49:11,266 --> 00:49:12,533
936
00:49:12,533 --> 00:49:13,033
Thank you.
937
00:49:13,033 --> 00:49:13,800
938
00:49:13,800 --> 00:49:20,733
So similarly, while the presence
of so similarly, I want to ask a
939
00:49:20,733 --> 00:49:27,433
little bit about this question
related to an indwelling medical
940
00:49:27,433 --> 00:49:28,200
device.
941
00:49:28,200 --> 00:49:31,566
So we know that indwelling
medical devices are a major risk
942
00:49:31,566 --> 00:49:35,866
factor for being colonized with
or being at risk for becoming
943
00:49:35,866 --> 00:49:38,033
colonized with an MDRO.
944
00:49:38,033 --> 00:49:40,266
945
00:49:40,266 --> 00:49:45,333
Can you talk a little bit more
about use of medical devices
946
00:49:45,333 --> 00:49:48,633
that might only involve limited
physical contact between a
947
00:49:48,633 --> 00:49:52,966
healthcare worker and a resident
and the use of gloves and
948
00:49:52,966 --> 00:49:55,500
gowns in in that type of
situation?
949
00:49:55,500 --> 00:49:56,666
950
00:49:56,666 --> 00:49:57,800
Yeah, thanks, Kara.
951
00:49:57,800 --> 00:49:59,900
I am happy to expand on that a
little bit.
952
00:49:59,900 --> 00:50:00,500
953
00:50:00,500 --> 00:50:05,500
One example that I like to give
is that say you have a staff
954
00:50:05,500 --> 00:50:08,666
member that's going to pass
medications through a feeding
955
00:50:08,666 --> 00:50:09,033
tube.
956
00:50:09,033 --> 00:50:09,700
957
00:50:09,700 --> 00:50:14,000
And although this is only
appropriate if the activity is
958
00:50:14,000 --> 00:50:18,500
not bundled together with other
high contact prolonged care
959
00:50:18,500 --> 00:50:22,800
activities and there's no
evidence of ongoing MDRO
960
00:50:22,800 --> 00:50:27,000
transmission in the facility,
the safest practice would be to
961
00:50:27,000 --> 00:50:31,500
wear a gown and gloves for any
care or use of an indwelling
962
00:50:31,500 --> 00:50:32,633
medical device.
963
00:50:32,633 --> 00:50:33,200
964
00:50:33,200 --> 00:50:37,233
But facilities can define these
limited contact activities in
965
00:50:37,233 --> 00:50:42,400
their policies and procedures
and educate healthcare personnel
966
00:50:42,400 --> 00:50:45,366
so they can ensure consistent
application of enhanced barrier
967
00:50:45,366 --> 00:50:49,200
precautions when it comes to
these brief interactions that
968
00:50:49,200 --> 00:50:49,600
occur.
969
00:50:49,600 --> 00:50:51,600
970
00:50:51,600 --> 00:50:52,066
Thank you.
971
00:50:52,066 --> 00:50:53,866
972
00:50:53,866 --> 00:50:59,400
I want to comment or I want to
ask you to comment also on PPE
973
00:50:59,400 --> 00:51:00,100
storage.
974
00:51:00,100 --> 00:51:00,833
975
00:51:00,833 --> 00:51:04,933
So, so speaking about PPE,
where, where should PPE be
976
00:51:04,933 --> 00:51:06,733
storage stored with EBP?
977
00:51:06,733 --> 00:51:07,933
978
00:51:07,933 --> 00:51:09,200
Yeah, Thanks, Kara.
979
00:51:09,200 --> 00:51:11,400
This question has come up often.
980
00:51:11,400 --> 00:51:12,500
981
00:51:12,500 --> 00:51:16,400
CDC continues to recommend that
PPE is located immediately
982
00:51:16,400 --> 00:51:20,566
outside of the resident鈥檚 room or
at the entry to the resident鈥檚
983
00:51:20,566 --> 00:51:20,900
room.
984
00:51:20,900 --> 00:51:21,700
985
00:51:21,700 --> 00:51:24,833
And we've discouraged the
practice of storing the PPE in
986
00:51:24,833 --> 00:51:29,133
the room primarily because there
is a risk of contamination.
987
00:51:29,133 --> 00:51:29,933
988
00:51:29,933 --> 00:51:33,833
This is one specific question
where many of you have pointed
989
00:51:33,833 --> 00:51:37,433
out previously that CDC and CMS
have responded slightly
990
00:51:37,433 --> 00:51:38,200
differently.
991
00:51:38,200 --> 00:51:38,900
992
00:51:38,900 --> 00:51:45,333
However, our key message aligns,
PPE should be readily available
993
00:51:45,333 --> 00:51:48,533
for a staff member to use when
they are planning to provide
994
00:51:48,533 --> 00:51:52,866
high contact resident care and
whether stored inside or
995
00:51:52,866 --> 00:51:55,800
immediately outside of the
resident鈥檚 room, the facility
996
00:51:55,800 --> 00:52:00,133
should make every effort to
avoid contamination of that PPE.
997
00:52:00,133 --> 00:52:02,266
998
00:52:02,266 --> 00:52:06,333
Thank you, Heather. Now I know we are,
we are nearing the end of our
999
00:52:06,333 --> 00:52:10,100
time, but I did see that there
were a couple of questions
1000
00:52:10,100 --> 00:52:13,700
specifically asking about the
studies that were shared.
1001
00:52:13,700 --> 00:52:17,233
And these are available in the
the there or resources that we
1002
00:52:17,233 --> 00:52:19,000
will include with these slides.
1003
00:52:19,000 --> 00:52:23,233
And they are also available on
the CDC EBP web page.
1004
00:52:23,233 --> 00:52:23,800
1005
00:52:23,800 --> 00:52:26,133
So you can take a look and
review in more detail.
1006
00:52:26,133 --> 00:52:26,333
1007
00:52:26,333 --> 00:52:30,866
I did want to ask the Washington
State Department of Health had
1008
00:52:30,866 --> 00:52:35,266
shared with us an analysis done
looking at cost effectiveness of
1009
00:52:35,266 --> 00:52:38,433
EBP Bola very quickly in the
last minute.
1010
00:52:38,433 --> 00:52:41,600
Are you able to share briefly
what they've learned?
1011
00:52:41,600 --> 00:52:45,066
1012
00:52:45,066 --> 00:52:46,033
Sorry, yeah.
1013
00:52:46,033 --> 00:52:50,733
So with Washington State HAI
program and I don't see them on
1014
00:52:50,733 --> 00:52:52,600
the call, but that's OK.
1015
00:52:52,600 --> 00:52:53,000
1016
00:52:53,000 --> 00:52:58,066
So they had done a cost analysis
of skilled nursing facilities
1017
00:52:58,066 --> 00:53:03,300
using enhanced barrier precautions,
looking at their implementation
1018
00:53:03,300 --> 00:53:09,166
like how much it costs versus
the cost of contact precautions,
1019
00:53:09,166 --> 00:53:12,633
implemented contact precautions
and the C. auris outbreak
1020
00:53:12,633 --> 00:53:13,733
investigation.
1021
00:53:13,733 --> 00:53:14,233
1022
00:53:14,233 --> 00:53:17,866
And the specific nursing home
that they looked at was 100
1023
00:53:17,866 --> 00:53:18,333
beds.
1024
00:53:18,333 --> 00:53:19,466
1025
00:53:19,466 --> 00:53:23,766
And they had ten different
residents essentially that have
1026
00:53:23,766 --> 00:53:27,600
foley catheters that would have
met the enhanced barrier
1027
00:53:27,600 --> 00:53:32,633
precautions implementation
criteria.
1028
00:53:32,633 --> 00:53:33,000
1029
00:53:33,000 --> 00:53:39,433
And they also learned that if
they looked at residents needing
1030
00:53:39,433 --> 00:53:43,500
the indication for contact
precautions.
1031
00:53:43,500 --> 00:53:44,000
1032
00:53:44,000 --> 00:53:48,800
That again, looking at the cost,
the aggregate costs, they
1033
00:53:48,800 --> 00:53:53,766
determined that they would need
an RN to provide six contact
1034
00:53:53,766 --> 00:53:58,833
care activities per resident per
day with the CNA providing 4
1035
00:53:58,833 --> 00:54:04,000
contact activities per resident
per day and cleaning products,
1036
00:54:04,000 --> 00:54:10,533
also for C. auris that have to be
specifically noted with the kill
1037
00:54:10,533 --> 00:54:16,900
claim as well as the
germicidal bleach wipes for C. auris,
1038
00:54:16,900 --> 00:54:22,633
and also screening time for
staff or resident depending in
1039
00:54:22,633 --> 00:54:27,100
terms of what residents were C. auris
positive.
1040
00:54:27,100 --> 00:54:27,700
1041
00:54:27,700 --> 00:54:33,600
So they overall determined that
for that specific instance in
1042
00:54:33,600 --> 00:54:36,233
implementing contact
precautions, they would have to
1043
00:54:36,233 --> 00:54:43,900
spend about $945 per residence
in that isolation room.
1044
00:54:43,900 --> 00:54:45,466
1045
00:54:45,466 --> 00:54:49,633
And again, like I don't see
Carolyn on the call, but if you
1046
00:54:49,633 --> 00:54:54,166
guys would like more information
about their study, please feel
1047
00:54:54,166 --> 00:54:59,833
free to reach out to your HAI
program, but it was shared by
1048
00:54:59,833 --> 00:55:02,100
Washington State HAI program.
1049
00:55:02,100 --> 00:55:04,600
1050
00:55:04,600 --> 00:55:05,266
Thank you, Bola.
1051
00:55:05,266 --> 00:55:08,333
And I want to thank the audience
again for joining us today.
1052
00:55:08,333 --> 00:55:08,866
1053
00:55:08,866 --> 00:55:12,166
Thank you to our speakers,
Doctor Bola Ogundimu and Doctor
1054
00:55:12,166 --> 00:55:15,266
Heather Jones, greatly
appreciate you sharing with this
1055
00:55:15,266 --> 00:55:16,100
audience today.
1056
00:55:16,100 --> 00:55:16,866
1057
00:55:16,866 --> 00:55:21,800
And we will be working on
putting all of this information
1058
00:55:21,800 --> 00:55:24,233
on the web so that you are able
to refer back to us.
1059
00:55:24,233 --> 00:55:25,800
Thank you so much again for
joining us.
1060
00:55:25,800 --> 00:55:26,200
1061
00:55:26,200 --> 00:55:29,533
And just real quick, Kara, I
wanted to respond.
1062
00:55:29,533 --> 00:55:32,566
There's been a lot of people
that are asking about the link
1063
00:55:32,566 --> 00:55:33,233
for the FAQs.
1064
00:55:33,233 --> 00:55:33,900
1065
00:55:33,900 --> 00:55:38,566
The best that I can share now is
if you will go into your search
1066
00:55:38,566 --> 00:55:43,433
engine and type CDC Enhanced
Barrier precautions.
1067
00:55:43,433 --> 00:55:44,000
1068
00:55:44,000 --> 00:55:48,066
You will be able to get to our
primary slide and you scroll all
1069
00:55:48,066 --> 00:55:51,866
the way down and then it will
take you to a link that says
1070
00:55:51,866 --> 00:55:53,600
frequently asked questions.
1071
00:55:53,600 --> 00:55:58,166
That is one of the best areas to
find more defined answers to
1072
00:55:58,166 --> 00:56:00,133
many of the questions that have
been asked today.
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