By Kelly M. Pyrek
An aging population is swelling the ranks of long-term care (LTC) residents in this country, and the need is greater than ever for the implementation of infection prevention and control in these facilities. Barriers to good practice are numerous for both the frontline healthcare worker and the infection preventionist (IP), but these can be combated with the right skill sets and knowledge, emphasizes Gail Bennett, RN, MSN, CIC, of Rome, Ga.-based ICP Associates, Inc. who has spent many years consulting to LTC facilities and health systems across the country and who was a co-author of the SHEA/APIC guideline on infection prevention and control in the long-term care facility.
Bennett believes there are several overriding issues that are critical right now for relating to LTC facilities' ability to establish and maintain knowledge of infection prevention among healthcare professionals in a highly challenging environment.
"Although we see great dedication among long-term care IPs, it is very difficult for the long-term care IP to get comprehensive training," Bennett says. "Sometimes deficient training is due to lack of funding to travel to conferences or to other off-site training programs. In the last few years I have been encouraged because many states are now taking on that issue by providing infection prevention training within the state. I am already seeing some improvement in the companies I have worked with in that more of their people seem to be going to official infection prevention training courses than they have been able to do in the past. There are also some good online training programs, but my concern is that not all IPs in LTC are aware of them. Additionally, some IPs in LTC have good access to computers while others do not. The issue of training IPs is critical to having a solid, comprehensive infection prevention program."
A second confounding factor related to education and training, Bennett says, is chronic staff turnover in LTC settings. "General staff turnover is challenging, but loss of staff members who have been appropriately trained to monitor and run the infection prevention program is even more of a problem," she says. "In the past I have worked with a corporation that owned 12 LTC facilities and for several years I was able to measure their turnover in the infection prevention position and that company had a 68 percent turnover every year. Despite having a corporate infection prevention consultant, as well as providing full-day, onsite infection prevention training classes three times a year with continuing telephone support, they still had an 68 percent turnover rate during the period of measurement. I don't really know the reasons, but many times these infection preventionists left to perform a different job at a different facility."
Bennett points to published data on overall high employee turnover rates in LTC facilities; 2011 data from the Quality Long Term Care Commission showed the following turnover rates: administrators, 3 percent; director of nursing, 39 percent; RNs, 50 percent; LPNs, 49 percent; and CNAs, 71 percent. "To me, it is alarming that the overall turnover rates are so high."
A report prepared for the National Commission for Quality Long-Term Care by the Institute for the Future of Aging Services (2007) outlined the various short-term trends in long-term care that complicated workforce recruitment and retention, including negative industry stereotyping; low wages and scant benefits; poor working conditions; and inadequate or misplaced investments in LTC workforce education and training. A significant long-term trend that is exacerbating the situation is the emerging care gap between the number of individuals requiring care and the number of available care providers. Persistent nursing shortages and nursing students' lack of exposure to the geriatric nursing career path can make it difficult to hire and train appropriately credentialed staff members.
This revolving door of turnover emphasizes what Bennett calls a "lack of redundancy" in the infection prevention position at LTC facilities. "Many times when the IP leaves employment, there is no one else in the building who has the knowledge needed to run the infection prevention program," she says. "One thing I have been preaching for a long time but I am still not seeing widely, is that every program needs -- at the minimum -- one person trained as back-up for the IP. That individual should have a higher level of general infection prevention knowledge plus training on managing the overall infection prevention program. We must have a back-up because if we are looking at 68 percent turnover in that position, we are losing the knowledge we have been able to procure in that facility."
A third consideration related to staff education and job performance is the LTC infection preventionist's lack of time to devote to her duties, a problem shared equally by acute-care comrades. "The challenge is having enough time to perform the specific infection prevention functions; even if she has the knowledge she has trouble finding the time, and frequently finding more time to allocate to the IP has not been a priority among LTC facility leadership," Bennett says. "We know that the LTC IP is wearing many hats and sometimes the infection prevention portion of her job is quieter than the others in that it does not immediately demand her attention. If she is doing staffing for the building, or doing orientation and training and teaching, and unless she is in an outbreak situation, then infection prevention may be on the back burner."
As with her acute-care counterparts, the LTC IP is charged with not only keeping herself educated, but educating and training frontline care providers who may have considerable knowledge gaps.
"One thing that could be very helpful among all staff is teaching them about the epidemiology of specific organisms and how transmission occurs because there's so much misinformation and sometimes confusion about precautions needed for multi-drug resistant organisms (MDROs)," Bennett says. "So I think knowledge of how certain organisms are transmitted and how we break that chain of infection by use of excellent hand hygiene and other precautions is very important. The second thing looming in infection prevention these days is knowing the importance of the environment and its role in possible infection transmission, and certainly in LTC with C. difficile and norovirus we know the environment can play an important a role. Staff must understand that things are done differently when addressing those two organisms in particular."
Bennett adds that along with C. difficile and norovirus, pathogens such as multidrug-resistant Acinetobacter baumanii and Carbapenem resistant enterobacteriaceae (CRE) are critical issues to address in the LTC environment right now. "The No. 1 consideration is having knowledge of these organisms, their significance, and if there are important environmental changes that need to be made in that room to assist in preventing transmission. The second intervention is considering careful resident placement. LTC facilities frequently do not have private rooms, so patients residents are may be rooming with someone who may have a serious infection with an MDRO. If private rooms are unavailable, placement with an appropriate roommate that would be considered low risk should be considered. A third intervention is compliance with hand hygiene and with implementation of appropriate precautions, and as we do that, we must also integrate observation in our infection prevention programs. When I teach about infection prevention I always say that "if you don't look, you don't know." We have to ensure good compliance with evidence-based practices as well as our policies and the best way to do that is through observation. The programs that may be more successful in performing ongoing observation are programs that have infection prevention liaisons who have had additional training in observation and documentation. These liaisons can be very helpful to the infection preventionist who may not be able to conduct observation herself. The last intervention is to gather good data on those pathogens of concern, and ensure that the data used to identify infections shows that those cases meet the surveillance definitions."
An approach that can have a significant impact on reducing infections in long-term care is implementing targeted strategies according to the organisms that present a problem in the facility, including making smart decisions about the use of transmission-based precautions. In the LTC environment we can't afford to be sloppy. We must have excellent practices, implementing standard precautions as well as transmission-based precautions as warranted, and that is where we make more of a case-by-case decision than is done in acute care. For example we frequently do not implement contact precautions simply because someone is colonized with a resistant organism, but we often do if they have an active infection. In hospitals they tend to put anyone with colonization in contact precautions. But we are working in the resident's home and our decisions always take that into consideration. Fortunately, the CDC isolation guidelines specific to LTC also considered that. Again, as we think about targeted strategies with our precautions, and we must include the component of observation."
As Smith and Bennett, et al. (2008) note, "Barrier precautions are important in preventing cross-infection with known resistant microorganisms, but approaches to isolation of LTCF patients colonized or infected with MDROs vary substantially across facilities. Most LTCFs employ at least some type of isolation for MDROs. It was found that 90.5 percent of facilities accepting patients with MRSA stated that they followed Contact Precautions despite only 39.7 percent placing them in private rooms. In another survey, most LTCFs were aware of and often screened for MRSA and employed some precautions in dealing with these residents (e.g., single room, cohorting, contact isolation, or placing the resident with MDRO in the same room as a low-risk roommate). Another study demonstrated no difference in transmission of MDROs in a skilled care unit between contact isolation precautions and routine glove use. The authors suggested that universal glove use may be preferable to contact isolation because it reduces social isolation for LTCF residents where their healthcare facility is also their home. Others have suggested a 'modified' contact isolation protocol as often more appropriate in the LTCF setting. Clearly, additional evidence-based studies defining the specific isolation needs within LTCF are needed."
HICPAC isolation guidelines attempt to address some of the specific needs and concerns of the LTCF.
According to Smith and Bennett, et al. (2008), the guidelines provide recommendations on the use of transmission-based isolation precautions. In LTCFs, it is advised to consider the individual resident’s clinical situation when deciding whether to implement or modify the use of Contact Precautions in addition to Standard Precautions if colonized or infected with an MDRO. Standard Precautions are sufficient for relatively healthy and independent residents, ensuring that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool and ostomy tubes/bags. Contact Precautions are indicated for residents with MDROs who are ill and totally dependent upon HCWs for activities of daily living or whose secretions or drainage cannot be contained. Single rooms for these residents are recommended if available. The cohorting of MDRO residents is acceptable if single rooms are not available. If cohorting is not possible, then placing residents with MDRO with residents who are low risk for acquisition or with anticipated short lengths of stay is advised. While ‘‘low risk for acquisition’’ of an MDRO has not been officially defined, one source suggested that it should include residents who are not immunosuppressed; not on antibiotics; and free of open wounds, drains, and indwelling urinary catheters. Case-by-case decisions, as needed, can be made regarding the best precautions to use for each resident with a MDRO. With Contact Precautions, wearing a gown and gloves for all interactions that may involve contact with the resident and their environment is advised, and eye protection is recommended when there is risk of splash or spray of respiratory or other body fluids."