By Jennifer Gutowski, MPH, CIC, Surveillance Coordinator, Philadelphia Department of Public Health

The Philadelphia Department of Public Health (PDPH) promotes and protects the health of 1.5 million residents of Philadelphia, in part through surveillance of over 70 communicable diseases and conditions. Of these diseases, few are considered healthcare associated and traditionally, outside of institutional outbreaks, PDPH has had a limited role in healthcare associated infection (HAI) surveillance and prevention. That role began to change as reports of carbapenem-resistant Enterobacteriaceae (CRE) clusters in long-term care facilities (LTCFs) began to demand attention from PDPH in 2012, and the local level was drawn deeper into the realm of HAIs. Since the beginning of 2013, when PDPH was awarded a grant from NACCHO to build HAI capacity, efforts to prevent antimicrobial resistance have been greatly enhanced in Philadelphia. Through the NACCHO HAI project, PDPH sought to address identified gaps via baseline assessments of multi-drug resistant organism (MDRO) prevalence and infection prevention within acute and long-term settings and through facilitation of HAI education.

Increasing HAI Capacity
Prior to 2013, PDPH had a limited ability to detect HAIs; without staff dedicated to HAIs and access to the National Healthcare Safety Network (NHSN), a national surveillance system for HAIs, the primary HAI activities of the health department were influenza and norovirus outbreak investigations in LTCFs. Additionally, PDPH had limited resources to develop and disseminate HAI guidance to acute and LTCFs. With the NACCHO HAI grant, PDPH was able to hire a part-time program assistant and develop a long-term care toolkit for HAI and MDRO prevention and control. Also, HAI education for current staff was provided through an infection-prevention training course, Council for State and Territorial Epidemiologists HAI workshop, and the certification of one staff member in infection control.

Communication with HAI partners, such as the Pennsylvania Department of Health, Association for Professionals in Infection Control and Epidemiology (APIC), and Quality Improvement Network for Pennsylvania hospitals, has developed into ongoing collaboration. The NACCHO HAI grant has been especially useful for helping the state and local levels learn more about what the other is accomplishing and investigating in the HAI realm.

Assessing the MDRO Burden
PDPH initially focused HAI efforts on assessing incidence of CRE in Philadelphia and establishing a collaborative for MDRO/CRE prevention. Using a modified version of the Centers for Disease Control and Prevention (CDC) CRE Toolkit survey, in December 2012 PDPH contacted infection preventionists at all 18 acute-care hospitals to determine the burden of CRE and solicit ideas for how best to assist the healthcare community. PDPH received completed surveys from 10 hospitals (56%). The feedback was diverse but indicated that CRE was a wide-spread problem in Philadelphia, with every responding hospital reporting cases in 2012. PDPH administered a simplified version of the acute care survey by phone to infection control nurses at all 47 Skilled Nursing Facilities (SNF) in summer 2013. Results from 29 (62%) SNFs showed that CRE was not as well recognized or prevalent within SNFs, with 28% of facilities reporting that they were not aware of CRE and only 39% of responding facilities reporting any CRE in the previous year. Only 70% of SNFs were aware of proper infection control procedures for CRE compared with 100% in hospitals.

To further define the health department’s role in CRE prevention, PDPH recruited local infectious disease physicians, infection preventionists, and microbiologists to form an MDRO advisory group. When asked if CRE should be a reportable condition, infection preventionists voiced concern as to burden and whether reporting would facilitate public health action in addition to offering just data. The consensus was that PDPH would be most helpful to the healthcare community as a facilitator of inter-facility communication and education, specifically for LTCFs.

Facilitating HAI-Prevention Education
With direction from the MDRO Advisory Group, PDPH planned a regional MDRO symposium for the healthcare community in fall 2013, focused on CRE prevention and antimicrobial stewardship. The one-day symposium featured keynote presentations by local and national experts in MDRO prevention, breakout sessions on laboratory testing and prevention in LTCFs, and a panel discussion. Through NACCHO support, the conference did not have a registration fee, and continuing education credits were provided for physicians and nurses.

Educational materials developed by PDPH and distributed at the symposium included an inter-facility transfer form for patients and residents with MDROs, a CRE fact sheet for patients, an acronym list, and a CRE report form. All materials and symposium presentations were also posted on PDPH’s health information portal (https://hip.phila.gov) for continued access. The CRE report form was designed for voluntary reporting, specifically targeted to LTCF cases, to prompt outreach from PDPH to the facility. The purpose of the outreach was to determine if assistance was needed in investigating transmission and to offer education and resources.

The success of the Infection Prevention Symposium, attended by 150 healthcare professionals, helped to spread the word among the healthcare community that CRE was an urgent threat to public health. After the symposium, voluntary CRE reports increased; however, they were geographically biased because only a subset of hospitals were reporting cases. PDPH has been involved in investigation of several CRE clusters and outbreaks within acute and long-term care. Health department involvement includes site visits, staff in-services, facilitating pulsed-field gel electrophoresis testing at CDC, and consulting with state and federal partners when needed.

PDPH also developed an HAI prevention toolkit for LTCFs, incorporating guidance from CDC, state health departments, and professional organizations. Staff within LTCFs will have a single source for HAI prevention methods. The toolkit will be distributed in hardcopy and will be made available electronically.

Creating Sustainable Collaboratives
Following the 2013 Infection Prevention Symposium, PDPH continued to call upon the MDRO Advisory Group to guide future activities. To address MDROs effectively, PDPH needed to promote antibiotic stewardship in addition to disseminating infection and control guidance and performing HAI surveillance. Group discussion discovered that acute care hospitals varied considerably in their antimicrobial stewardship activities. Several local academic hospitals with established stewardship programs offered to assist with promoting antimicrobial stewardship within the region. The first step was to bring together all professionals with an active or potential role to share ideas and best practices from their facilities. PDPH identified these individuals through e-mail requests to hospital contacts, asking them to provide the contact information for those involved or potentially involved in antimicrobial stewardship at their hospitals. Prior to the meeting, PDPH developed a survey to assess current antimicrobial stewardship activities at acute care hospitals and distributed it to all stewardship contacts via Survey Monkey. As planning evolved, one local hospital system was awarded a community education grant, which supported a regional educational antimicrobial stewardship meeting and research project.

The first Antimicrobial Stewardship Collaborative Meeting brought together more than 85 healthcare professionals from 30 healthcare facilities, non-profits, and government agencies in the Philadelphia region. Continuing education credits, offered to physicians, nurses, and pharmacists, helped to increase attendance at the meeting. A local antimicrobial stewardship expert provided a national perspective and a summary of local capacity, determined from the surveys distributed prior to the meeting. Presentation topics included social and behavioral determinants of antibiotic prescribing, practical strategies for applying antimicrobial use data, and local antimicrobial stewardship experiences at acute care hospitals. PDPH surveyed attendees about their interest in future regional antimicrobial stewardship activities; responses received by 51 (59%) attendees showed willingness to participate in bi-annual in-person meetings, educational webinars, an antimicrobial stewardship list service, and quarterly conference calls.

In addition to antibiotic resistance, PDPH is focused on preventing blood-stream infections (BSI) and transmission of blood-borne pathogens within hemodialysis facilities. PDPH became interested in hemodialysis infection prevention after investigating a large hepatitis C outbreak at a local facility in 2013. Opportunities for prevention education were discovered during this investigation, and PDPH is working with dialysis facilities to establish a BSI prevention collaborative to promote CDC tools and review local NHSN data.

Looking to the Future
With limited HAI resources, PDPH has found strength in community collaborations with regional MDRO experts. PDPH has used community partnerships to create and promote educational efforts. The local APIC chapter has added to the success of large-scale educational events. Facilitating meetings to promote discussion and exchange of ideas within the regional healthcare community has defined PDPH’s early role in HAIs. Future goals include gaining access to NHSN to understand better the local HAI burden and needs. PDPH hopes to continue local HAI efforts with continued support through small grants and community support.

This article was originally published in NACCHO Exchange. To read the entire issue, download the newsletter from NACCHO’s online bookstore. (Login required).