Understanding Long-Term Care's Unique Challenges

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By Kelly M. Pyrek

With the U.S. healthcare reform mandate for increasing transparency and improved quality, the need for infection prevention and control in long-term care facilities (LTCFs) is becoming more critical than ever before for the more than 3 million Americans receiving geriatric care in U.S. annually. In January, the Association for Professionals in Infection Control and Epidemiology (APIC) published the Infection Preventionist’s Guide to Long-Term Care to assist facilities in creating and implementing comprehensive infection prevention programs.

Infection preventionists in LTCFs face unique challenges due to the nature of the care setting and its aging resident population. An estimated 1.5 million infections occur annually in LTCF, resulting in 350,000 to 400,000 deaths. “APIC is committed to increasing educational resources for long-term care to advance knowledge and competencies of healthcare personnel working in this setting, and for the benefit of the residents under their care,” says APIC CEO, Katrina Crist, MBA. “With more than 15,000 long-term care facilities in the United States, and a national priority to prevent healthcare-associated infections, APIC’s new book guides LTCFs through the essential components of an evidence-based infection prevention program.”

The Infection Preventionists Guide to Long-Term Care is accompanied by a CD-ROM with customizable forms, tools, and resources. Developed by a team of infection prevention experts, the book presents topic-specific information in a user-friendly format that includes numerous examples, visuals, checklists, and references to help increase the understanding of regulatory requirements, comprehensive infection prevention risk assessment and program development, surveillance and reporting, nursing assessment and interventions to prevent the most commonly occurring infections in long-term care, environmental cleaning and disinfection, unique long-term care issues such as care transitions and life enrichment activities, occupational health, immunization programs, and staff education, as well as disaster and pandemic preparedness.

Compared to an acute-care setting, long-term care can seem like a brave new world. LTC guide co-author Deborah Patterson Burdsall, MSN, RN-BC, CIC, in her chapter addressing Understanding Infection Prevention in Long-Term Care, outlines the realities of infection control in a skilled nursing facility: "Sixty percent of LTCFs are for-profit. A profit-driven structure can produce high-resident/HCP ratios and supply restrictions as a strategy to produce profit and reduce costs. Both high-resident/HCP ratios and supply restrictions result in less time for care, a decreased ability to keep the environment clean, and encourage cutting corners when performing infection prevention activities. Lapses in infection prevention activities not only increase the risk of intra-facility transmission, but also are often correlated with citations by the Centers for Medicare & Medicaid Services (CMS) Survey and Certification. If nursing assistants, nursing departments, and infection prevention and control programs are not supported, and if there are insufficient supplies, outbreaks of infectious diseases can be well established before nurses or primary care providers are aware they exist."

For infection preventionists crossing from acute-care into long-term care, there are some principles and practices that are universal, says Steven J. Schweon, RN, MPH, MSN, CIC, HEM, an infection prevention consultant in Saylorsburg, Pa.

"The evidenced-based universal principles and practices of infection prevention are applicable across the life-span and practice setting," Schweon says. "Hand hygiene, aseptic technique, vaccination, environmental hygiene, antibiotic stewardship, surveillance, etc., are very pertinent, promote good outcomes, and can be applied to residents and patients of all ages."

Schweon says that as someone who has transitioned from acute-care to long-term care, there are several key points to continually keep in mind:
- Many of the residents have multiple co-morbidities such as diabetes, functional decline, altered sensorium, failure to thrive, incontinence, and obesity, which may be challenging to control and also increases their infection risk.
- LTC resources, both human capital and equipment, are more limited when compared to acute care. Staff turnover may be higher when compared to acute care.
- The staff and residents will be very receptive to receiving the infection preventionist’s knowledge with reducing infection risk and promoting wellness. The IP may achieve greater job satisfaction as a LTC IP when compared to their acute-care role.
- There is the potential to form very gratifying, long-term relationships, with both the resident and the family, in addition to the employees

IPs going into long-term care must be aware of the characteristics of these residents, as Burdsall points out that, "With an average age of 80 years, older adult residents generally live in LTCFs because of a self-care deficit or a medical condition that requires constant and consistent support. Residents require assistance ranging from cues and reminders to total dependence and are more likely than those who are living independently to have conditions such as: Increased frailty, dementia, decreased immune function, decreased skin integrity and wounds, problems with nutrition, chewing, and swallowing, issues with incontinence, decreased bowel and bladder function, and decreased mobility."

In addition to unique resident characteristics, there are numerous staff-related issues such as lack of healthcare provider education, staff turnover due to working conditions and lower pay, and challenges related to multiple staff from different cultures that either reinforces or challenges prior beliefs, cultural taboos, teachings, and behaviors.

Burdsall advises that IPs, as well as all healthcare personnel working in long-term care, provide a "person-centered approach to maintain health and avoid preventable infection." She adds, "It is estimated that there are between 1.6 and 3.8 million infections annually in elderly residents of LTCFs. The population of individuals over age 85 is expected to grow to 7.3 million by 2020, and a focus on preventable infection is critical since the personal and economic expense of infection is high."

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