11/2/2016

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Hopefully Helpful: Long-Term Care Hot Topics

Regulatory Changes

Glove Use in Long Term Care

Standard, Enhanced Standard, and Transmission-Based Precautions

Deb Patterson Burdsall PhD, RN-BC, CIC, FAPIC

Learning Objectives

•Describe the proposed CMS Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities as they relate to infection prevention and control programs in long-term care

• Identify the potential for cross contamination associated with the use of non-sterile clinical gloves

•Review policies and procedures relating to Centers for Disease Control and Prevention (CDC) Transmission-based Precautions for organisms commonly found in long-term care

Part I Long-Term Care

Regulatory Changes and Infection Prevention and

Control

New Territory

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Personal Cost of Healthcare Associated Infections (HAI)

•Between 1.6 and 3.8 million (HAIs) in nursing homes every year

•Infections result in an estimated 150,000 hospitalizations, 388,000 deaths

CMS Long-Term Care Participation Revisions 2016

•Revises participation requirements for Medicare and Medicaid programs

•The changes reflect evidence-based practice

•CMS working to achieve broad-based improvements

•Quality of health care

•Patient safety

•Reduce procedural burdens on providers

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Burdsall, D.P. (2011, unpublished manuscript) There and Back Again: A Germ’s Tale. * How 1983-2009 Admission and Discharge Data from a Suburban Long Term Care Facility Illustrates Increased Risk of MDRO Transmission Between Acute and Long Term Care.

* with apologies to J.R.R. Tolkien

Illustrates change from

LTC as “home” to

LTC as “rehab”

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Major Changes

•Infection Prevention and Control Program

•Dedicated Infection Preventionist

•Specialized training, education, certification, or experience

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Major Changes

•Antimicrobial Stewardship including antibiotic use protocols and a system to monitor antibiotic use

•Coordinate and participate in QAPI

•National Healthcare Safety Network (NHSN) (not required as of 2016…yet)

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Antimicrobial Stewardship

•Require antibiotic stewardship program, antibiotic use protocols, and a system for monitoring antibiotic use

•CDC Core Elements for LTC

•Policy and Practice Review and Change

•Leadership

•Accountability

•Tracking antibiotic use and outcomes

•Education

•Drug Expertise

The Core Elements of Antibiotic Stewardship for Nursing Homes http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

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Infection Prevention and Control Program (IPCP)

•Require a system for

•Preventing

• Identifying

•Reporting

• Investigating

•Controlling infections and communicable diseases

•All residents, staff, volunteers, visitors, and other individuals providing services

•based upon facility and resident assessments that are reviewed and updated annually

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Facility-wide Assessment

• “Determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies”

•The facility must review and update thatassessment:

•As necessary

•At least annually

• “Whenever there is, or facility plans for, any change that would require a substantial modification to any part of this assessment”

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Source: Federal Register Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities

Must Address: Residents, Patients, and Clients

• The facility’s resident population, including, but not limited to:

• Number of residents

• Facility’s resident capacity

• The care required by the resident population:

• Types of diseases

• Conditions

• Physical and cognitive disabilities

• Overall acuity

• Other pertinent facts that arepresent within that population

• Any ethnic, cultural, or religious factors that may potentially affect the care provided:

• Activities

• Food

• Nutrition 12

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Must Address: Building and Operations

•The physical environment and resources•Equipment •Services (therapies, pharmacy, rehab services)•Other physical plant considerations necessary to care for population•All buildings •Physical structures •Vehicles•Equipment (medical and non-medical)•Contracts, memorandums or 3rd party agreements

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Must Address: Personnel

•Staff competencies that are necessary to provide the level and types of care needed for the resident population

•Any ethnic, cultural, or religious factors that may potentially affect the care

•Services provided

•All personnel, including managers, staff (both employees and those who provideservices under contract), and volunteers, as well as their education and/or training and any competencies related to resident care

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Education

•Goal: staff comply with infection control practices

•Initial and ongoing infection control education

•Updated education and training

•When policies and procedures are revised

•When there is a special circumstance (e.g. outbreak)

•Requires modification or replacement of current practices.

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Training and Competency

•Task and discipline-specific infection control training

•insertion of urinary catheters

•suctioning

•intravenous care

•blood glucose monitoring

•Follow-up competency evaluations identify staff compliance

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“A facility-basedcommunity-based

risk assessment, utilizing an all-hazardsapproach”

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Qualified Infection Preventionist

•Designate specific infection preventionist (IP) (Infection Preventionists)

•Position may be shared

•Require education/training, certification, or experience for IP responsible for Infection Prevention and Control Program

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Quality Assurance and Performance Improvement (QAPI)

•Maintain documentation and demonstrate evidence of ongoing QAPI program

•Present the QAPI plan to the State Agency Surveyor

•Address all systems of care and management practices

• Include clinical care, quality of life, and resident choice

•Utilize the best available evidence to define and measure indicators of quality and facility goals

•Reflect facility case mix and care

Quality Assurance Performance Improvement (QAPI)

•Element 1: Design and Scope

•Element 2: Governance and Leadership

•Element 3: Feedback, Data Systems and Monitoring

•Element 4: Performance Improvement Projects (PIPs)

•Element 5: Systematic Analysis and Systemic Action

QAPI Tools

•Tools for each of the 5 QAPI Elements

•University of Minnesota and Stratis Health

•CMS created “process” tools

•Use to implement and apply some of the basic principles of QAPI

•A Process Tool Framework has been created to crosswalk each CMS Process Tool to the QAPI Five Elements

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapitools.html

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CMS Infection Prevention and Control Program (IPCP) Reform of Requirements for Long-Term

Care Facilities

Phase I

November 28,

2016

Basis and Scope

Definitions

Basic IPCP

Phase II

November 28, 2017

IPCP linked to Facility

Assessment

Antibiotic stewardship

Phase III

November 28, 2019

Infection

preventionist (IP)

IP participation on QAA committee

(QAPI)

Summary• Infection Prevention and Control has been prioritized in long-term care

•Illinois already requires long term care facilities to have an IP

•The CMS regulations enhance current Illinois requirements

•CMS has provided tools in the QAPI toolkit

•Risk-based programs are required.

•Long term care may benefit by looking at psychotropic reduction as a model for antimicrobial stewardship

PART IIEXPLORING

INAPPROPRIATE GLOVE USE IN LONG-TERM CARE

Burdsall, et al., 2016. Exploring Inappropriate Glove Use in Long Term Care Manuscript submitted for publication

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Background

•Patient care requires human touch

•Healthcare personnel (HCP) frequently wear exam gloves during patient care to protect themselves from blood, body fluids, and other potentially infectious materials that may contain pathogens

•Gloves protect HCP and patients when used appropriately

•When HCP use gloves inappropriately they may spread pathogens and increase the risk of healthcare associated infection (HAI)

Barbara Fassbinder1953-1994Source: Hilchey, J., 1994

Purpose

1. Describe the degree of inappropriate glove use with the structured observational tool

2. Explore the association between inappropriate glove use and selected HCP and patient care event characteristics

3. Determine the interrater reliability of the Glove Use Surveillance Tool (GUST ©)

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GUST© Tool

•The Five Facets of Glove Use©

1. Touch Points (Gloved and Bare-Handed)

2. Gloved Touch Points

3. Glove Change Points

4. Actual Glove Changes

5. Glove Changes at a Glove Change Point

GUST© Tool

•Two Indicators of Inappropriate Glove Use ©

1. Failed Glove Changes

2. Contaminated Touch Points

Results

•Degree of inappropriate HCP glove use

•HCP overused gloves

•HCP failed to change gloves 66% of the time when a glove change was indicated

•Over 44% of the HCP gloved touch points were defined as contaminated

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N = 351Glove Change Points

N = 121

Glove Changes at Glove Change Point

N = 230

Failed Glove Changes

N = 802

Contaminated Touch Points

N=76 HCP

in 76 Patient

Care Events

9590 88

8075 73

42 39

28 25 2316 15 13 11 10

0

10

20

30

40

50

60

70

80

90

100

Setting up a “field” of wipes

Repeatedly handling the wipes packages with contaminated gloves during the patient care event to get additional wipes

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Conclusions•Gloves have been shown to be a powerful tool for protecting both HCP and patients

• If HCP continue to use gloves after touching surfaces contaminated with blood, body fluids, or other potentially infectious materials they may cross contaminate between patients and the healthcare environment

•HCP used gloves inappropriately in 83% of the patient care events in this study

•The GUST© was shown to be a reliable tool in this study

Future Steps•Glove use is an under-examined phenomenon

•Missing link in cross contamination of healthcare environment?

•More study needed about how and why HCP use gloves

•Remove barriers to appropriate glove use

•Develop effective training and monitoring systems

•The goal is cost effective, evidence-based interventions to prevent healthcare associated infections

PART III

PRECAUTIONS, OUTBREAKS, AND A SOCIAL MODEL OF

CARE

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Standard PrecautionsEnhanced Standard PrecautionsTransmission-Based Precautions

•Standard Precautions:

•Transmission Based Precautions

•Enhanced Standard Precautions•For lower risk residents/patients (e.g. independent, can perform hand hygiene, continent, with no uncontained wounds)•Hand hygiene when entering resident room•Gown and gloves for hands-on care (e.g. toileting,

wound care and suctioning)

Source: * Prevention, Control, and Management of Carbapenem-Resistant Enterobacteriaceae in Long Term Care Facilitieshttp://www.dph.illinois.gov/sites/default/files/publications/management-cre-ltcf-040516.pdf

Burdsall High C’s of Infection Prevention and Control

Clean Hands and Gloves

Clean Clothes

Clean Equipment and Environment

Contained Drainage

Covered Wounds

Careful Assessment

Careful Use of Antimicrobials

Collaborative Approach

Communication

Standard Precautions and Transmission Based Precautions in a Social Model

Biopsychosocial

Model of Care

Epidemic or Outbreak Situation

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Respiratory:Viral pneumonia in Older adults

•Comorbidities increase the risk of infection and complications

•Decline in innate immune functioning may impair viral clearance

•Loss of respiratory muscle strength and mucous levels allows viruses to spread more easily to the lower respiratory tract causing inflammation

Source: Mosenifar, Z., & Hoo, G. W. S. (Eds.). (2006). Practical pulmonary and critical care medicine: Disease management. CRC Press.

•

Cost of Hospitalization with Pneumonia in Medicare Beneficiaries

•50% hospitalization rate

•30 day mortality HAI 13.4% CAI 6.4%

•$15,682 higher medical costs compared to matched control patients without pneumonia

•Annual excess cost hospital treated pneumonia is estimated conservatively at > $7 billion in 2010

Thomas , et al., Chest. 2012 Oct;142(4):973-81.

Influenza Vaccination•Vaccinate healthcare workers

•Encourage families and visitors

•Older adults- High Dose (HD) vaccine works!

•Persons 65 years of age or older:

•Significantly higher antibody responses

•Provided better protection

•Well-tolerated and more immunogenic

1. DiazGranados, C. A., Dunning, A. J., Kimmel, M., Kirby, D., Treanor, J., Collins, A., ... & Talbot, H. K. (2014). Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults. New England Journal of Medicine, 371(7), 635-645.2. Tsang, P., Gorse, G. J., Strout, C. B., Sperling, M., Greenberg, D. P., Ozol-Godfrey, A., ... & Landolfi, V. (2014). Immunogenicity and safety of Fluzone< sup>®</sup> intradermal and high-dose influenza vaccines in older adults≥ 65 years of age: A randomized, controlled, phase II trial. Vaccine, 32(21), 2507-2517.

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What does this type of outbreak look like in the middle of Influenza Season?

0

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All Influenza-like illness residents, families, employees

ALL

Lab Confirmed Influenza A

Importance of identifying circulating viruses

•Viruses play a larger role than previously thought

•Estimated that 13-50% of pathogen-diagnosed community-acquired pneumonia are viral in origin

•8-27% of cases as mixed bacteria-virus infections

•Targets treatment and avoids unnecessary medication

•Reduces cost with targeted use of oseltamivir

• Stops comments like: • “I got a flu shot and I still got the flu”

Mosenifar, Z et al., (Eds.). (2006). Viral Pneumonia.

Respiratory Virus Panel: PCR from Swab, Aspirate or Washing

•Human Metapneumovirus (FAR, ESR, TAG)

•Rhinovirus (FAR, ESR, TAG)

• Influenza A (FAR, ESR, TAG, VRV)

• Influenza B (FAR, ESR, TAG, VRV)

•Enterovirus (FAR)

•RSV (FAR, ESR, TAG, VRV)•Parainfluenza Virus (FAR, ESR, TAG)•Adenovirus (FAR, ESR, TAG)•Coronovirus (FAR)•B. pertussis (FAR)•C. pneumoniae (FAR)•M. pneumoniae (FAR)

• www.viracor.comSlide: Peterson, L

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With Viral Identification

0 0 0 0

1

0

2

1 1

0

4

1

0 0 0 0

3

1 1 1

2

0 0 0 0

1

0

1

0 0

1

0 0 0 0 0 0

1

0 0 0 0

0

0

0

0 0

0

0

0

0 0 0 0

0

0 0 0

0

0 0 0 0

1

0

0

1 1

0

0 0

1

0 0 00 0 0 0

0

0

0

0 0

0

0

0

0 0 0 0

0

1

2

1

1

1

2 2

1

3

0

2

0 0

2

1

0

0

0 0 0

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1

0 0 0 0

1

0

0

0

2

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0

0

0

1

0 0

0

0

0

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1

0

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0 0

0

0

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0

0

1 1 1 1

2

0

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5

6 Influenza A Influenza B Pos RSV Other

CDC Isolation Precautions

•Adenovirus- Contact and Droplet Precautions

• Influenza A and B- Droplet Precautions

•Human Metapneumovirus (hMPV)- Contact Precautions

•Respiratory Syncytial Virus (RSV)- Contact Precautions

•Enteroviral infections (i.e., Group A and B Coxsackie viruses and Echo viruses) (excludes polio virus) Standard Precautions

•BUT “Use Contact Precautions for diapered or incontinent children/persons for duration of illness and to control institutional outbreaks”

Source CDC: 2007

Multiple viruses in the same cohort

•A person could be sick with influenza A

•Then come down with influenza B

•Then RSV

•Then adenovirus

•Or be sick with more than one virus at a time

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Intervention Bundle

•Communication, within facility, interfacility, and with public health

•Hand Hygiene

•Interdisciplinary cleaning and disinfecting

•Twice a day temperatures

•Focus on avoiding presenteeism in staff and visitors

•Mask training and use

•Restrictions on group activities, and movement

How to Wear a Mask

Perform Hand Hygiene

Remove Mask from Box- wear yellow side out

Place mask over nose, mouth and chin

Fit flexible nose piece over nose bridge

Secure on head with ties or elastic

• Adjust to fit. Try pulling at the bottom for comfort

• The front of the mask is considered contaminated and should not be touched after it is fitted

• Change when coming out of isolation room

• Change if soiled or touched when wearing in public areas

• Remove by handling only the ties or elastic bands starting with the bottom then top tie or band.

• Lift the mask or respirator from the face and discard it into the trash. Perform Hand Hygiene

Source CDC.gov PPE use

Discontinuing Transmission-based Precautions in Outbreak

•Contact/Droplet Precautions•7 days •48 hours after completion of therapy when asymptomatic and afebrile

•Follow either IDPH LTCF•Acute gastroenteritis recommendations (AGE)•Influenza like illness (ILI)

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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 01

0 01 1 1

3

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

0 0

0 01

0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

01

1 1

2

5

01

0 0 0 0 0 01

0 0 0 0 0 0

Influenza B and RSV Mixed Respiratory

March 2013

7 Influenza B, 1 RSV, and 12 unknown

20 cases 198 x15= 20/2970 person days

x1000 = Rate of 6.73 ILI per 1000 person

days

Influenza B Pos RSV Other

Started Bundled

Approach

1 1 1

1

1 1 1

4

1

1

Respiratory Complex Definition:

Cough, Weakness, Fever, Infiltrate

Attack Rate 27%

Met Definition of Respiratory Complex: No Testing

Confirmed Combined HMPV and RSV

Confirmed HMPVStarted Bundled Approach

Started Bundled Approach

Norovirus is Not Influenza

•Norovirus is a stomach virus

•There is no vaccine for norovirus

•Pay attention to residents, patients, volunteers, and staff who complain they are nauseated or who have loose stools or vomiting

•Send employees, visitors, volunteers or clients home

•Keep residents or patients in their rooms

• Immediately place residents or patients with these symptoms on Droplet/Contact Precautions

•Clean all surfaces every 1-2 hours with advanced hydrogen peroxide or bleach/detergent wipes

•Wash hands with soap and water

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FOR COMPARISON 2011Norovirus Confirmed Gastrointestinal Outbreak101 Cases/453 Residents = 22% Attack Rate.

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11/6/11 11/13/11 11/20/11 11/27/11 12/4/11 12/11/11 12/18/11 12/25/11 1/1/12 1/8/12 1/15/12

0

0.5

1

1.5

2

2.5

Acute Gastroenteritis Dementia Unit January 20138 cases on 1 unit =42 residents

Attack Rate: Residents and Staff 6.6%Attack Rate: Residents only 16%

9 Cases: 3 Confirmed Norovirus

SX

Case Def

2 per. Mov. Avg. (SX)Confirmed

Norovirus

THANK YOU!!! WHAT A GOOD JOB!You stopped an outbreak!!!

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3/19/2015 3/20/2015 3/21/2015 3/22/2015 3/23/2015 3/24/2015 3/25/2015 3/26/2015 3/27/2015 3/28/2015 3/29/2015 3/30/2015

2nd Floor Acute Gastroenteritis Cases Surrounding Confirmed Norovirus

Confirmed Norovirus

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Lessons Learned

•Prompt identification of symptoms and use of Transmission-Based Precautions is critical

•Not everyone with confirmed respiratory illness OR norovirus met the case definition. Don’t ignore subtle symptoms if there is an association with a case

•QI project determined outbreaks responded quickly when everyone was identifying, isolating, and cleaning/disinfecting with the proper products in this care community

Hospitals, Long Term Care, Home Care, Home Health, and Public Health must communicate and work

together

HUMAN

Spiritual

Psychological

Biological

Social

Infection Prevention and Control is a Human issue, and needs to be dealt with within a biopsychosocial and

spiritual framework

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THANK YOU!

• Lutheran Home/Lutheran Life Communities Staff, Residents, and Families

• Dr. Stephanie Black, and the entire Chicago Department of Public Health team

• APIC and APIC Consulting Services

• Northwest Community Healthcare Micro and Reference Lab

• Dr. Lance Peterson, Dr Richard Thompson, Donna Schora, Anna Marie Ogle, Marc-Oliver Wright and the NorthShore University Health System Laboratory

• Judith Conway, IDPH

• Dr. Loreen Herwaldt and University of Iowa Hospitals and Clinics Epidemiology and Infection Prevention

• The University of Iowa College of Nursing

Thank youDburdsall@gmail.com

Nothing to disclose

References

• American Healthcare Association (AHCA). Quality Report, 2014. Retrieved from https://www.ahcancal.org/qualityreport/Documents/AHCA_2014%20Quality%20Report%20FINAL.pdf

• Boyce, J. M., & Pittet, D. (2002). Guideline for Hand Hygiene in Health-care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. American Journal of Infection Control, 30(8), S1-S46.

• Boyce, J. M., Pittet, D., & Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. (2002). Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 23(12 Suppl), S3-40. doi:10.1086/503164

• Burdsall, et al., 2016. Exploring Inappropriate Glove Use in Long Term Care Manuscript submitted for publication.• Burdsall, et al., 2016. Testing the Reliability of the Glove Use Surveillance Tool (GUST). Manuscript submitted for publication.• Burdsall, et al., 2016. Glove Use in Long Term Care and the Protection Motivation Theory: New Use of an Established Theoretical Framework.

Manuscript submitted for publication.• Castle, N. (2011). Nursing home deficiency citations for abuse. Journal of Applied Gerontology, 30(6), 719-743.• Centers for Disease Control and Prevention [CDC], (2004). National Study of Long-Term Care Providers, retrieved from

http://www.cdc.gov/nchs/nnhs.htm • Centers for Disease Control and Prevention [CDC], (2004) The National Nursing Assistant Survey (NNAS), retrieved from

http://www.cdc.gov/nchs/nnas.htm• Centers for Disease Control and Prevention [CDC], (2012). Prevention Process Measures Surveillance for Long-term Care Facilities, retrieved from

http://www.cdc.gov/nhsn/PDFs/LTC/LTCF-Prev-Process-Measures-Protocol_FINAL_8%2024%2012.pdf• Centers for Disease Control and Prevention [CDC], (2014). National Study of Long-Term Care Providers, retrieved from

http://www.cdc.gov/nchs/nsltcp.htm• Centers for Disease Control and Prevention [CDC], (2014). Infection Prevention and Control Recommendations for Hospitalized Patients with Known

or Suspected Ebola Virus Disease in U.S. Hospitals, Retrieved from http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

• Centers for Disease Control and Prevention [CDC]a, (2015). Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE, Retrieved from http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html

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References, continued• Centers for Disease Control and Prevention [CDC]b, (2015). Surgical Site Infection. Retrieved from http://www.cdc.gov/HAI/ssi/ssi.html.

• Centers for Disease Control and Prevention [CDC]c, (2015). Nursing Home Care. Retrieved from http://www.cdc.gov/nchs/fastats/nursing-home-care.htm

• Centers for Medicare and Medicaid Services [CMS], 2015a. State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, Rev 149

(10-9-15). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

• Centers for Medicare and Medicaid Services [CMS], 2015. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/downloads/qapifiveelements.pdf

• DiazGranados, C. A., Dunning, A. J., Kimmel, M., Kirby, D., Treanor, J., Collins, A., ... & Talbot, H. K. (2014). Efficacy of High-Dose versus Standard-Dose Influenza

Vaccine in Older Adults. New England Journal of Medicine, 371(7), 635-645.

• Falsey, A. R. (2008). Human metapneumovirus infection in adults. The Pediatric infectious disease journal, 27(10), S80-S83.

• Hilchey, J., (1994). Barbara Fassbinder, 40, Nurse With AIDS Traced to Her Job. New York Times, Published: September 22, 1994. Retrieved May 1, 2016 from

http://www.nytimes.com/1994/09/22/obituaries/barbara-fassbinder-40-nurse-with-aids-traced-to-her-job.html

• Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities 7/16/15. Retrieved from

https://www.federalregister.gov/articles/2015/07/16/2015-17207/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities

• McKibben, L., Horan, T., Tokars, J. I., Fowler, G., Cardo, D. M., Pearson, M. L., ... & Healthcare Infection Control Practices Advisory Committee. (2005). Guidance on

public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. American journal of

infection control, 33(4), 217-226.

• Mosenifar, Z et al., (Eds.). (2006). Viral Pneumonia. Retrieved from http://emedicine.medscape.com/article/300455-overview#a0104

• National Clearinghouse Long term care www.longtermcare.gov

• Ouslander, J.G., Lamb, G., Perloe, M., Givens, J.H., Kluge, L., Rutland, T., et al. (2010). Potentially avoidable hospitalizations of nursing home residents: Frequency,

causes, and costs. Journal of the American Geriatrics Society, 58, 627-635

• Smith, P. W., et al., (2008). SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. American Journal of Infection Control, 36(7), 504-

535.

• Siegel, Reinhardt, Jackson, Chiarello, HICPAC (2007) Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings.

• Strausbaugh, L. J., & Joseph, C. L. (2000). The burden of infection in long-term care. Infection Control and Hospital Epidemiology ,21(10), 674-679.

• Thomas, C. P., Ryan, M., Chapman, J. D., Stason, W. B., Tompkins, C. P., Suaya, J. A., ... & Shepard, D. S. (2012). Incidence and cost of pneumonia in Medicare

beneficiaries. CHEST Journal, 142(4), 973-981.

• Timmel, D., & Taube, A (2009) PASRR Intensive: Nuts and bolts of preadmission screening and resident review (PowerPoint) retrieved from http://www.public-

health.uiowa.edu/icmha/meetings/1018-2109/documents/TimmelPASRRNutsBolts.pdf

• Tsang, P., Gorse, G. J., Strout, C. B., Sperling, M., Greenberg, D. P., Ozol-Godfrey, A., ... & Landolfi, V. (2014). Immunogenicity and safety of Fluzone< sup>®</sup>

intradermal and high-dose influenza vaccines in older adults≥ 65 years of age: A randomized, controlled, phase II trial. Vaccine, 32(21), 2507-2517.

• National Clearinghouse Long term care www.longtermcare.gov