Effective, efficient movement of patients through the post-acute continuum of care is Kindred’s goal. But infectious diseases are unwelcome visitors that also like to make the post-acute continuum of care their home, starting in the acute care hospital and settling in at the various levels of post-acute care settings.

 Alice Kim, MD, Medical Director of Infection Control at Kindred Hospital Cleveland. Alice Kim, MD, Medical Director of Infection Control at Kindred Hospital Cleveland.

Addressing issues related to infectious diseases today at Kindred’s Fifth Annual Clinical Impact Symposium was Alice Kim, MD, Director of Infectious Disease/Control at Kindred’s Cleveland Fairhill Hospital.

Dr. Kim, who came to Kindred from the Cleveland Clinic with the mission of implementing acute-hospital devised infectious disease plans in the post-acute setting, described the challenges related to infectious diseases in both acute and post-acute care.

The incidence of infections in the post-acute setting, according to Dr. Kim, is comparable to the rate and number in acute care hospitals, and infections are the primary reason for 25 to 50 percent of transfers back to acute care hospitals from long-term care, a trend that Kindred and other healthcare providers will be looking to address as rehospitalizations continue to be penalized under the Affordable Care Act.

So why do post-acute care patients have infections and why is there such a high mortality rate? Post-acute patients have many characteristics that pre-dispose them to infection contraction.

These include:

  • Advanced age
  • Immuno-suppression
  • Co-morbid disease
  • Functional limitations
  • Fecal and/or urinary incontinence
  • A depressed mental state
  • Presence of medical devices (including tracheostomy, feeding tubes, urinary and central vascular catheters, etc.)

Residence in group quarters and bouncebacks between care settings allows the spread of infections between the acute care hospital and long-term care settings. A high rate of antibiotic use leading to multi-drug resistant organisms keeps the problem alive.

Common infections in long-term care settings include:

  • Urinary Tract Infections (predisposing factors include immobility, incontinence, catheters, stroke, antibiotic prophylaxis)
  • Pneumonia and ventilator-associated pneumonia (VAP), which has a tenfold higher rate in long-term care settings than in the community, risk factors for which include underlying cardiopulmonary disease; witnessed aspiration; sedation medications, overall poor functional status
  • Skin and soft tissue infections
  • CVC (central venous catheter –associated) infections
  • Bacteremia, or infection in the bloodstream. This has a particularly high mortality rate and 50 percent of deaths happen within 24 hours of diagnosis
  • C Difficile, which causes life-threatening diarrhea, and 90 percent of deaths from C Diff are in the over 65 set. C Diff is transmitted primarily through person-to-person contact through the fecal/ oral route. It also produces spores that can survive in the environment. Risk factors include advanced age, duration of hospitalization and exposure to antimicrobial agents
  • MRSA (Methicillin Resistant Staphylococcus Aureus), which is responsible for 80,000 invasive infections per year). Common sites include pneumonia, UTI, skin and soft tissue, conjunctivitis
  • CRE (Carbapenem Resistant Enterobacteriaceae), which normally live in water, soil and the human gut. CRE have developed a high level resistance to antibiotics. CRE was uncommon in the United States before 1992, and is now reported in 42 states in the last 10 years
  • KPC (Klebsiella Pneumoniae Carbapenemase), which can cause hemorrhage and inflammation in the lungs. It can be transmitted to other genera including E. coli and salmonella and, in turn, make them resistant. Risk factors include: exposure to health care (especially the ICU); use of antimicrobials; poor functional status; severe illness; mechanical ventilation; indwelling catheters; diabetes; malignancy. Removal of focus (through catheter removal, debridement or drainage) can improve survival

So what can we do to prevent and to better treat these infections?

Dr. Kim said there are several things to keep in mind. First, the appropriate and judicious use of antibiotics must be practiced; attention must be paid to infection versus colonization; matching drugs to bugs – knowing the resistance pattern in the facility and locally; and keeping an eye to recent culture results with adjustment based on new culture results.

Dr. Kim shared some methods for improving diagnosis and treatment of infections in the post-acute setting, including improvement of communication between nursing staff and standardization of methods for consistent and accurate information collection and reporting.

An Infection Control Committee should review and monitor appropriate antibiotic use. Antibiotics should be used only when appropriate. And finally, Dr. Kim’s last suggestion is one that participants have heard from other Symposium speakers related to communication – pick up the phone. It’s old-fashioned, but good communication between clinicians is key to good infection control.

Dr. Kim pointed out that studies have shown improved outcomes at lower cost with Infectious Disease consultation. Those include:

  • 3.8 percent shorter overall stays
  • 5.1 percent shorter ICU stays
  • 2.8 percent lower acute hospital charges
  • 3.4 percent lower Medicare payments to all providers for stays

Dr. Kim’s presentation was met by a lively and animated Q & A period with participants asking questions related to their own challenges and successes at their respective facilities.

Alice Kim, MD, Medical Director of Infection Control at Kindred Hospital Cleveland.