Taking Healthcare by Storm: Industry Insights with Dr. Ghinwa Dumyati

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Ghinwa Dumyati, MD, Director of the Communicable Diseases Surveillance and Prevention Program at the University of Rochester Medical Center.

Dr. Dumyati discusses infectious disease management in long-term care facilities, focusing on COVID-19, vaccination, infection control, antimicrobial stewardship, and combating multi-drug resistant organisms like Candida auris. She highlights the importance of collaboration between healthcare facilities and public health to address current and emerging threats. 

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website. 

This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-ARPA-030725-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

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 Hello, everyone, and welcome to another episode of Taking Health Care by Storm. I am Dr. Jean Storm, the Medical Director at Quality Insights, and our guest today is Dr. Renwa Dumyati, an Infectious Disease Physician and Professor of Medicine at the University of Rochester Medical Center. Dr. Dumyati leads the Communicable Disease Communicable Diseases Surveillance and Prevention Program, and she is a renowned expert in emerging infectious diseases and vaccine effectiveness, something that is, these topics are so very relevant currently.

With extensive experience in antibiotic stewardship, quality improvement, and public health research, her work is currently supported by the CDC. She also serves on the Palt Med Infection Advisory Subcommittee and is a fellow of the Society for Healthcare Epidemiology of America. We are going to explore critical topics related to infection prevention, vaccination, and the future of healthcare, primarily for nursing home residents.

Dr. Jumiaty, thank you so much for joining us today. Yeah, thank you so much for the invitation. Great, so tell us how you came to do what you do and maybe just give a little bit of background for people to what is an infectious disease doctor and then what is your role in long term care facilities and nursing homes?

Yeah, so an infectious disease doctor, I guess, is the doctor that is probably experienced at diagnosing and treating infectious diseases but also has other roles such as infection control and public health. So I presently my main role is more public health. I work with the CDC emerging infections program.

And I perform surveillance, or what we do, tracking of infectious disease that are significant to public health. I also have done quality improvement project and antimicrobial stewardship project, and I can talk some more about it during our conversation today. And my interest, really, in long term care started during one of my quality improvement projects.

I work with the local hospital on a project to reduce Clostridium difficile infections. And for people who don't know what Clostridium difficile infection is, that is, causes diarrhea and is often associated with use of antibiotics. It became very clear when I was doing this work that how, you know, interconnected hospital and long term care facility were.

Because patient often moves back and forth between these settings, so it's impossible to address some infection control, you know, at one place without addressing it at another place. So around a decade ago I started, you know, kind of my pursuit to work with a nursing home. Specifically because of the C.

diff, I wanted to reduce it. We you know, I got the nursing home collaborative locally with multiple medical director being involved, and we work together on trying to reduce C. diff by improving antibiotic use And and since then I have been really still working with the medical director locally and nationally.

And and I also joined the Health Med Infection Advisor Subcommittee. And during COVID 19, the committee was really quite active. At the beginning of the pandemic, we were creating infection control guidance, and we were also addressing vaccine and vaccine hesitancy, and we had a lot of guidance, you know, kind of developed and disseminated.

And and I'm very happy to work in this space because it's very rewarding and you feel like you're making a difference. Yeah, I mean, yes, you're the front lines. Definitely. So let's just start. You mentioned COVID. So how has the manage of COVID 19 in nursing homes evolved since the pandemic began?

And what strategies do you recommend for preventing future outbreaks within the facilities? Yeah. So going back to the start of it, you know, we really it was a very big challenge. Early, you know, we were, we really didn't have much information or knowledge, but so we focused on controlling outbreak and we did it with a restriction of visitation.

We had mass testing. We had use of Personal protective equipment or PPE. And at that time, there was a big challenge with PPE. It was not readily available and the big challenge was staffing. And so it was quite hard to manage these outbreak over time. You know, we learned better how to prevent and control the spread of COVID 19.

But really what made a real difference is the vaccination. When the vaccine, you know, became available and what, you know, was was used in both staff and in resident, you know, we saw that there was a difference in the number of cases in the facilities that had high vaccination rate. And we also learned about, you know, how to do better infection control, better cohorting of infected individual.

and how to do surveillance and how to improve airflow. And so what helped with COVID is we got infection control and to the forefront. And we really educated a lot of staff on infection control and infection prevention practices. So moving, you know, kind of sustaining this, what we really need to is really a very strong infection control program.

We need to make sure that facility have an infection control practitioner that's able to provide the time necessary to do a good job. I know that, you know, from my experience, many have to wear multiple hats, which will be, you know, difficult to manage all the tasks that are required. We also need to keep, you know, kind of staffing training for the basic, you know, basic infection to control use of hand hygiene, proper use of PPE.

We also need to have programs in place to do surveillance so we can capture the emergence of a respiratory illness in a patient and, you know, kind of doing, you know, testing and isolation so the infection doesn't spread. And we also what we have learned which is still very important is kind of nursing home are not present in silo, and they really have.

We need to have better communication between hospitals and nursing home and vice versa. And we need to work, you know, together on something like this, like covert outbreak. So these are my thoughts, you know, for the future, keep what we had, you know, started and set up and during COVID. Yeah, and I would agree and kind of jumping off from that do you feel the majority of nursing home residents are being appropriately treated for acute COVID infection?

And if not, why do you feel there's a hesitation in providing guideline based treatment? Yeah, this is you know, this is truly an important question. We know and there's the evidence that treatment makes a difference in outcome. I think and this population, you know, in a nursing home has, you know, people are older, have a lot of comorbidity.

So if they get an infection, they're more likely to be infected. sicker than your average, you know, adult in the community, but there's also higher risk for hospitalization and higher risk for death. What is, what has been some of the barrier to treatment is, you know, kind of, first of all, we need to make sure we have a, as I mentioned previously, a setup in place to make sure people are diagnosed early because you have a limited time to start treatment.

You know, the treatment is a little bit complex because specifically for Paxlovid because of the interaction with medication which required careful review and adjustment by prescribers. So some prescribers, you know, probably don't feel confident looking up interactions. So it's very important to work with a pharmacist and to look for potential interactions.

So, to set up a process for this ahead of time. So I just want to mention that I worked with the New York New York mda and we developed a resource resource website for multiple documents to tackle respiratory violence in this, in nursing home. And and I can provide the link which is covid dot.

Nymda, N Y M D A dot org. And on that website there is a lot of documents including consent form you know, treatment guidance testing guidance and so forth. But there is also a an Excel sheet that's already programmed where you could put the patient's medica creatinine and to adjust the medication for you know, just the antiviral including the flu antiviral, Tamiflu.

And the covid treatment as well. And it's all it's very important that for every patient in a nursing home that information is completed prior to the outbreak. And we know that, you know, most of the covid outbreak occur now in winter and late summer. So be ready and be kind of cognizant. You know, what do you need to do on each patient if they need to be treated?

So facilitating this is very important. This this process will make probably the provider more comfortable treating patients. There's also another, you know, kind of barrier, which not barrier, but misunderstanding, you know, people wait to treat and you shouldn't really wait because by the time they progress, it's kind of too late.

You should treat early, even, you know, if they have very few symptoms of COVID 19. So education of provider having someone to assist with a complex treatment on board such as your consultant pharmacist is helpful to make sure, you know, people are receiving guideline recommended treatment in the nursing home.

Yes, and I will say I've looked at this This website for these resources, and they're just fantastic. So I highly recommend it's covid dot N. Y. M. D. A. dot org. Really great resources. So how prevalent are multi drug resistant organisms, things we call M. D. R. O. S. In nursing homes. And what steps can health care providers take to prevent the spread of these infections in nursing homes?

So this is also a very important topic. And and I, you know, the prevalence of, you know, colonization with multidrug resistant organism is quite high in the nursing home. You know, up to probably 50 percent of nursing home can have one or multiple organism colonization from staph aureus carbapenem resistant antibacteria that Rallis or vancomycin resistant enterococcus.

And the issue is like, we don't test everyone to, you know, to capture this resistance. But we know when studies are done that often this population is highly colonized with this organism. And there are many reasons for for this, including kind of, a commonly common health care exposure to antibiotic, live in living in a communal setting where there is more kind of, risk of transmission between patients or between health care worker and patient and so forth.

So this population is highly colonized and To prevent kind of the transmission of these organisms, you know, we don't really presently recommend screening, but You know, you have to be cognizant of what are the risks of a healthcare person who is taking care of a patient to contaminate, you know, their hand or their clothing and, you know, not doing the right hand hygiene or not doing the cleaning of the environment appropriately and transmitting this organism to other patients, especially patients who have, for example, an open wound and you're changing the dressing.

for listening. or an intravenous line and so forth. So I think also I preach to go back to the basic and make sure that your staff is well educated on the basic infection control. So again I reiterate the importance of having a very strong infection control program with a dedicated infection preventionist.

And then, you know, making sure that hand hygiene compliance is high, making sure that alcohol gel is available, and I think that was some of the changes that occurred in the nursing home due to COVID 19, where, you know, there, you know, there was more acceptance of having alcohol gels in different places in the nursing home and then making sure that the environment is appropriately cleaned environments and service, you know, there's, Also like nursing in nursing home turnover is high.

So educating the personnel on, you know, why they are important and why, you know, and what's their role in prevention of infection and the nursing home. The other thing I want to, to also emphasize for MDRO, you know, is driven by antibiotic use. So also having an antimicrobial use antimicrobial program.

Antimicrobial stewardship program is also important. And another thing that people really don't think about. Is vaccination. Vaccination will prevent infection. For example, if you vaccinate for influenza or covid and it's less likely to get maybe a secondary bacterial pneumonia. If you're less likely to get pneumonia, you're less likely to use antibiotic, so you have to also think of vaccine implementation.

in addition to all infection control practices as a, an improvement of antibiotic use as measures to reduce the prevalence of multidrug resistant organism in this population. Those are such great tips. And I don't think many people think about vaccines in, you know, preventing MDROs. So you talked, you touched a little bit on antimicrobial stewardship.

in infection prevention. So what can facilities do to minimize the risk of antibiotic resistance, especially in elderly residents? So I, you know, I can tell you from my experience, how, you know, how I established programs and how we, you know, we were able to sustain them. And so, what is really important in a nursing home is to have a team that's dedicated and you have a champion that's going to drive the program.

It became very obvious that you cannot just have. in infection preventionist leading an antimicrobial stewardship program. When we started this was kind of like another task added to the infection, poor infection preventionist. What you really need is involvement of, you know, it should be multidisciplinary program.

So when I did it, I brought the medical director. I even brought the administrator on board because you need probably sometimes you might need funding for different things, maybe upgrading your computer system and so forth. And you need your, if you can get also get your consultant pharmacist involved.

So you need someone who has expertise in antibiotic to really lead this program. But you can still use the infection preventionist for surveillance, for looking at culture results. So what we did, for example, we empowered the infection preventionist to attribute the culture. to review the antibiotic that the patient was on and if the, for example, it's urine culture and the result shows that the there's a growth of a resistant organism that the present antibiotic doesn't cover she was empowered to reach to the clinician and say, hey, I got their test result and this patient, you have him on X, Y, and Z, and this organism is not sensitive.

So, And then with reducing antibiotic use, you're going to be reduced kind of the push to development of antimicrobial resistance. You know, one thing I, one thing that was really helpful when I went to the nursing home and asked the medical director, what do you think you'll help, would help you to know, like to improve your antibiotic use?

So one thing they said, you know, for example, We know we use a lot of quinolone. Can you tell us how much do we use? And can you tell us how appropriate is use? And can you give us alternative? So what we did is we established a process where we measured the antibiotics. We summarized them. We shared them.

We measure the appropriateness of treatment. For example, many people with asymptomatic bacteria are treated with antibiotics just because the culture is positive without evaluation for sign and symptoms. So we educated starting from frontline staff to up to the, you know, medical director of, you know, when is it appropriate to.

First test a urine because, you know, there is a high rate of conversation and you want to get a positive cultural and was it when is it appropriate to treat? And then we, they, they asked me, you know, give us guidelines for treatment. So we develop. You know, between us, Infectious Disease, plus the medical director, we developed treatment guidelines for the most common infection in the nursing home, and they are, you know, and there are some guidelines on our website, which is Rochester Rochester Collaborative.

I have to Russia's patient safety collaborative is our website that has all the guidelines, but there is also AHRQ guidelines that are also available and it's in the antimicrobial

So creating guideline education from frontline staff to all your medical staff is important. Also giving feedback. For example, when I presented the data on the appropriateness of treatment. for urinary tract infection. I was in the room and I said, you know, I noticed that many of you, you get a cultural result and I don't see a note.

I see just an antibiotic prescription. Why? Do you really, do you go and evaluate the patient when the cultural result is back or do you immediately just treat? So the blank faces, but it brought the message home that You know, you have to interpret the culture by look and look at the patient. You cannot just take a test result and intervene.

So, so doing all that, you know, we were eventually able to change reduce the treatment of, urinary tract infection and change the use of quinolone for treatment of urinary tract infection and pneumonia because we gave them guideline that didn't prioritize quinolone as the first line agent for treatment.

I can go on and on, but it's such an important topic about this topic. I can spend an hour talking about, yeah, it's really important topic. I mean, so you touched a little bit on, on vaccine, so really relevant currently. Have you found that there is an increase in vaccine hesitancy among nursing home residents or staff?

And do you think that this hesitancy has impacted infection rates in long term care facilities? So I don't have like, new data on, you know, what's happening when most of your staff and residents are not vaccinated, but we had data during COVID 19 that definitely showed that the higher the percentage of resident and nursing staff vaccinated, the less likely you're going to have patients developing COVID and you're going to have less COVID 19.

patient hospitalized and die from COVID. And I think it's a very difficult question to answer. Is there, is the hesitancy new or old? I think for staffing in the nursing home, even before COVID, the rate of vaccination, even for influenza was not great compared to the hospitals, at least locally, we saw very big differences.

And I think there's data recently in a recent MMWR Article from the CDC showing that vaccination, for example, for influenza is much better in the staffing in the hospital than it is for the nursing home and the vaccination for COVID 19 is really poor across both the hospital and the nursing home.

But even worse in the nursing home. So I think some of the issue hesitancy probably or being kind of, Reluctant to be vaccinated is probably a lot a, an issue that has been present before COVID, but be really be highlighted during the COVID outbreak pandemic. And you know that in the nursing home, many of the staffing are, you know, come from background that are kind of not trusting off of health care. Health care is vaccine in general. So educating, educating your frontline staff on you know, kind of the value of vaccine for them. And the patient is critical and try addressing their fears and addressing kind of, you know, Their misinformation about the value of vaccination or the effectiveness of vaccination is very important.

And I'm aware that the moving needles which is that moving needles dot org is a quality improvement project in the nursing home to improve vaccination. They have a great in service presentation. For to be given by a medical provider to frontline staff explaining kind of why do we need to vaccinate not just the resident, but yourself and why is it important to protect you and to protect the resident?

So I think a lot of education, a lot of sitting with a person understanding why. They are hesitant to be vaccinated, addressing their fear, addressing the misinformation is important. Sometimes you get them to change their minds, sometimes you don't. But this is kind of very important and we need to really improve vaccinations for both the resident and the staff and the nursing home.

Yeah, I would agree and that website is movingneedles. org and another. just wealth of information on that website for long term care facilities. So focusing a little bit about onto the R. S. V. Vaccine. So this is respiratory syncytial virus. Maybe people have stopped thinking about it a little bit. So do you feel that this vaccine is important for nursing home residents to receive?

It is quite important, and I am kind of, I feel I'm a little bit upset about the slow uptake for this vaccine. What is what is known is that you know, kind of, RSV or respiratory syncytial virus. Is a virus that causes morbidity and morbidity, mortality in the older population and the population with comorbidities.

What it does, it, you know, it exacerbates your you know, kind of respiratory status if you have asthma or COPD. It can cause congestive heart failure. It can cause myocardial infarction. And so we know that in the U. S. It's estimated that R. S. P. Causes approximately 100, 000 to 1 60, 000 hospitalization.

In older adult per year, and it leads to 6, 000 to 10, 000 off those patient dying. We locally have looked at it. Mhm. The burden off RSV in our nursing homes in the Rochester area. We have 33 nursing home and we we have, you know, uncovered that if you are hospitalized, one in four patients died during their hospitalization.

25 percent of people that are hospitalized and the The risk for hospitalization compared to an older adult in the community is approximately, you know, six times higher in this population. So I think RSV is a, is is a virus that causes You know, kind of severe disease in this population, and it's similar to, you know, what happened to people who didn't get vaccinated for covert or didn't get vaccinated for influenza as far as hospitalization.

And we, you know, what is. Is unfortunate is not everyone is aware of the burden of RSV because we don't routinely test for it. And I suspect that the uptake of this vaccine is low possibly because of people not being aware of, you know, the burden or the risk of this infection. So I looked up, you know, recently to see what's the data on uptake in the nursing homes.

And I found out that so far by November 2024 only 18 percent of the nursing home population has received the vaccine which is quite low and if you compare it to influenza, for example, by November 2024, it was 58 percent of the residents have been vaccinated. So we have some work I think there have been some barrier that is a the a warning about the memory with the to vaccine the 1, the appraisal and the recently, the FDA put a warning on the label.

And they they suggest that there is an increased risk of Gambari syndrome during the 42 days following vaccination. With those 2 vaccines, we don't have data with the MRNA vaccine, but, you know, although there is some increased risk, there is no evidence. The evidence is insufficient to establish a causal relationship.

And the ACIP still recommended because the benefit outweighs the risk. Yeah, and I don't think people realize how important it is, especially for nursing home residents. So you mentioned in the beginning of the podcast that you are on, serve on the Palt Med Infection Advisory Subcommittee. So Palt Med, for anyone who doesn't know, is the post acute and long term care association and So what role does this infection advisory subcommittee play in guiding providers and long term care facility?

Yeah, so we focus on what is, you know, what is a topic that is emerging that needs to be addressed. So, for example, prior to COVID we created guidance on, for example, testing and treatment for unit tract infection. During COVID, we had a lot of documents on you know, COVID infection control, COVID vaccination That we put out more recently where we're working on the document guidance document on the use of urine PCR for diagnosing urinary tract infection in the nursing home.

We do a lot of education during the Yearly meeting national yearly meeting. We also do podcasts and we have done a grand round on various topic related to infectious disease and infection control on. We're welcome. If anyone has, you know, kind of a gap or they want us to address something to reach out to us.

And we have a variety of members, including pharmacists and infection prevention. Practitioners so we can, you know, kind of get together and develop guidance for or answer questions related to infectious disease and infection control. Yes. Super, super important work. So maybe something not a lot of of individuals who are listening want to hear about, but norovirus.

We're experiencing increased cases of norovirus currently and you know, if you don't know what norovirus is, if you've had the gastrointestinal virus, you know, with vomiting and diarrhea, that may be what it is. So what is important for people to know about norovirus? Yeah, as you said, you know, we have a lot of norovirus and this year, the number of outbreak is much higher than preceding years.

I'm not sure why, but definitely many nursing home are seeing outbreaks. You know, and the problem with norovirus is the attack rate is very high, not just in the patient, but also in the staffing. And so, You know, I have gone through a managing a norovirus outbreak, you know, kind of a decade ago when I was a hospital epidemiology happened.

Nursing home is really hard to control once it kind of spread beyond one unit. So again, You know, as we talk about COVID surveillance and identifying patient early for isolation is key. So you have to educate your staff on, you know, sign and symptoms diarrhea, vomiting is quite common. And by the way, when the patient vomits that the virus is aerosolized to your exposure to vomitus, you have to make sure you protect your mucous membrane.

So, detecting the infection early to prevent the spread is key. The second thing is hand hygiene is very important. For norovirus, it's important to wash hand with soap and water, especially after you assist a resident in cleaning, you know, their stool. And and so the hand hygiene is quite important.

And then it also contaminates the environment. So it's very important to clean the environment in the patient's room and outside the patient room and very frequently you know, everything that's kind of, being touched, high touch surfaces, door handle, light switches and then make sure you're your environmental service staff is using the right agent.

Bleach is recommended or something that has a label that against new virus. And then it is important also to address staffing. You really need to monitor your staff. And if staff is ill, they should not be working. And they should not come back to work until 48 hours after resolution of their symptoms.

It's important also to Not just the cohort, the sick patient, but also cohort the staff. Don't have staff go between infected unit and non, not infected unit. And then and then, you know, kind of basically be proactive and make sure that you are aware of all the cases in both resident and staff and make sure everyone is following infection control practices.

Yeah very important. I've felt as medical director with many of these outbreaks in nursing homes And I will say you got to make sure that your facility smells like a swimming pool It's got to have that smell so last question Looking ahead. I mean, this is probably the question that I'm most interested in looking ahead.

What emerging or future communicable diseases do you foresee posing a significant risk to the nursing home population? And how can facilities proactively prepare for these potential threats? Yeah, the one that really is worries me, and we haven't had big outbreaks locally where I live, but definitely in New York City, is Candida auris, which is this multi drug resistant fungus that's, you know, affecting patients in both hospital and nursing home, specifically nursing home who have long term vent unit.

So it's a population that affects population that's quite debilitated. That's kind of where I think we have to educate and be aware about this this fungus. You have to You know, I reach out to our lab to make sure that they're able to detect this organism and not just detect it in sterile sites such as blood, but are they able to detect it in sputum and are they able to detect it in urine.

This fungus is quite hardy and it contaminates the environment. P patients that are colonized with it. It's a long term colonization, so it's kind of becomes harder to eradicate it. So that's kind of what's keeping me up at night these days. So locally we're having again, you know, you cannot have infection control on one end without addressing the other end.

So we're having you know, kind of meeting between all the hospitals and infection preventionists in town to address it, which we're starting to see a few cases pop here and there. And we want to be kind of all on board to prevent, you know, kind of large outbreak in our community. So being prepared and being aware of this fungus is is important.

Other things, you know, you probably heard about bird flu, H5N1. You know, we haven't had outbreak. There are a couple of severe diseases disease, but we don't know what's coming. So being ready to the next emerging virus. The rest of the virus infection is important. The other thing that's quite important also is.

Resistant bacteria such as carbapenem resistant enterobacteriaceae is is also of concern. And ultimately, I think to tackle all these, what we need are a strong infection control program, a strong medical director, strong surveillance and education of frontline staff about all the issues we discussed today.

And I think that's, you know, that's what keeps me up at night. Yes, and I will agree. I feel the same. But education, preparation, awareness, you know, that's what we need to do. Most definitely. And communication. I think we have learned, for example, how interconnected nursing home and hospitals are. And locally, for example, due to short staff, short staffing in our nursing home, you know, there's a backlog of patients that need to be discharged.

They're not able to be discharged. So our, emergency room are over capacity. Our hospital are over capacity. So it's very obvious that,  we cannot prepare for any emergency or an emerging infection without having great communication between hospital, long term care and also public health, you know, health department.

And we need to be ready for the next, big I guess outbreaks or pandemics. Yes. Agree. A hundred percent. But well, thank you, Dr. Jim Yantis for sharing all of this fantastic information today. I know it is, it was super helpful to me and I know it will be very helpful to our listeners. So thank you again for joining us today.

Thank you.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

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