Acute-Care, Long-Term Care, and Ambulatory Care
Championing Aseptic Technique in All Practice Environments
By Kris Ellis
The delivery of healthcare in the United States has undergone drastic changes over the past couple of decades. From the dramatic increase in procedures performed in outpatient settings to the explosive growth of long-term and home-based care, the landscape has been fundamentally altered.
The effort to control infection, as a vital component of patient care, must not only adapt to these changes, but also must be proactive in protecting healthcare workers and patients alike from an ever-expanding range of infectious threats. As patients and multi-drug-resistant organisms (MDROs) cross the boundaries of different healthcare settings more and more frequently, the specialized knowledge and experience of dedicated infection control practitioners (ICPs) is in great need.
Although each healthcare setting encompasses a unique set of circumstances that must be taken into consideration, many basic infection control principles can and should be applied to any environment.
The broad, general principles that apply everywhere are hand hygiene, aseptic technique, and environmental cleanliness, says Libby Chinnes, RN, BSN, CIC, president of Mount Pleasant, S.C.-based IC Solutions, LLC. Sometimes we do more in the perioperative setting with cleaning the environment; but cleaning the nursing home room and the acute-care hospital room should be the same. Sometimes we might use different disinfectants in the home, but were still disinfecting those environmental surfaces and also pieces of equipment for use on patients.
The one that is most consistent across every setting is hand hygiene, says Marie Kassai, RN, MPH, CIC, infection control professional for Kindred Hospital New Jersey. That crosses every setting that there is, both from the physician, patient, and healthcare worker standpoint. Kassai also mentions adherence to universal/standard precautions as a fundamental concern. Those are the two most important things and probably next would be isolation, and isolation varies in each of those settings because of the different patient populations that they have.
Christopher Florez, BS, CIC, director of infection control for San Antonio-based St. Lukes Baptist Hospital, notes that accreditation requirements should be considered in evaluating principles; specifically, those from the Joint Commission on Accreditation of Healthcare Facilities (JCAHO). He says hand hygiene is, of course, prominent in this respect, among other things. Theres also a paradigm shift to doing patient tracer methodology in that there is a key focus on communication in the healthcare setting, he says. Theyre really looking at communication along the continuum of care for the stay of the patient.
In terms of setting up an effective infection control program, Chinnes points to a joint report from the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America.1 The report talks about some of the differences in out-of-hospital settings, she says. However, some of the similarities in setting up an infection control program in any setting are that the goals for an infection control program are probably the same. There are three goals: protect the patient first, protect healthcare workers and visitors (a close second), and do it in as timely and cost effective a manner as you possibly can.
The report identifies the principal functions of infection control and epidemiology as:
- To obtain and manage critical data and information, including surveillance for infections
- To develop and recommend policies and procedures
- To intervene directly to prevent infections
- To educate and train healthcare workers, patients, and non-medical caregivers
Chinnes explains that the policies and procedures should be practical, science-based where possible, and monitored for compliance. Then we need to see if they are current with the literature, practical enough that the staff can follow through, and also that the staff are indeed following them, she says. Direct intervention to prevent infections means being proactive, as Chinnes points out. We usually dont wait until we have an outbreak; were intervening routinely, whether its in the nursing home, the patients home, or the surgery center, and directly in areas such as patient and staff education, performance improvement, patient care practices, and policies and procedures.
Education becomes increasingly important as patients encounter a broad range of settings and caregivers. As people are seen more and more in outpatient and home settings, now were training patients and their caretakers, who may or may not be medically oriented, Chinnes says.
As the traditional environment for infection control programs and practices, ICPs are intimately familiar with many of the issues that may arise and the guidelines and standards surrounding acute-care facilities. However, there are always plenty of emerging developments that require ICPs precious time and resources.
Florez again points to adherence to JCAHO standards, and the focus on patient tracer methodology. Once a patient is identified in the hospital as having an infection or the requirement for isolation, youve got to show some documentation for that, and then its got to be communicated, he says. What weve found in working with some JCAHO consultants is that you, as the ICP, will put an entry into the computer and then do your follow-ups as needed, you put some form of communication in there, and then its got to be followed by the practitioner at the bedside. Part of that is getting the information from caregiver to caregiver in a report, but it doesnt always happen, and that can be a showstopper for a hospital when it comes to the continuum of care and communication. These are things that are starting to really shift in the infection control realm.
Emerging infectious diseases also constitute a new risk that must be reckoned with. One of the most important things you have to do (in acute care) is patient assessment, Kassai says. Especially in the ER, its really critical to assess patients for any possible type of infection, and identify those infections that trigger additional preventive measures such as TB (tuberculosis) or SARS (severe acute respiratory syndrome), or something that requires that the patient be put in isolation.
Chinnes notes that with a sicker population, a host of resistant organisms, and patients who are having many more invasive procedures, the infection control effort is made even more challenging. Most of us are also trying to target our scarce resources because we cant follow everything and everybody every day, she says. We have to target the priority areas in our own facilities, and that usually involves the people with devices, like the people on vents for pneumonias, and the people with central lines for bacteremias. We may be able to look at everyone with bacteremias, but if we cant, we survey for central line-related bacteremias because we can do something about that. There are a lot of preventative measures we can take and monitor to try to control those infections.
Chinnes also points out that many patients in acute care settings have invasive lines, may be immuno-suppressed, and often have multi-drug resistant organisms (MDROs). Acute care is also constantly challenged with proper disinfection and sterilization of patient care equipment, including scopes, she continues. Of course, acute care is also revving up for potential bioterrorism. A part of their disaster plan, and a mandate from Joint Commission, is learning how to set up practices in terms of how we would deal with a rapid influx of infectious disease patients. What do we need to do? Do we need to isolate them or need more ventilators or special medicine? Do we know how to triage them and get them through our big hospital systems?
The only way to tackle this potentially monumental issue is extensive planning, according to Florez. Everybody has to be in synch with whats going on you cant just say, Youre going to do this, youre going to do that, and its all going to fall into place, because it will not happen that way. Any time you have a disaster or any type of emergency situation, you can almost be assured that somethings not going to go right.
Florez says a large part of the planning effort involves establishing capable leaders. He likens effective leadership in this type of situation to a military command center. Whoever runs that command center has to be pretty proficient in all aspects of preparedness for that type of event; not that theyre experts in every area, but you need to have people in place who are experts. In terms of infection prevention, we know different modes of transmission of infectious diseases, but the key for that type of event is having a system in place to identify your index cases and then track those people as they start to hit the ERs and hospital settings. Also, understanding the mode of transmission and being able to speak intelligently as to how you can prevent further exposure to other citizens in the community. Weve done it on paper, on blackboards, and in exercises, but until it actually happens, we dont know how were going to react.
Aside from the formidable clinical challenges ICPs face in acute-care settings, many are faced with the task of quantitatively justifying the need for an infection control program and the resources necessary to maintain it. We are not revenue generators we are cost avoiders, and getting the board of directors to understand that can be challenging, says Florez. So how do you measure the worth of the program? The only way you can do that is to put together a solid infection prevention program and show them the potential cost savings; the costs that you can avoid with the prevention of infection or lowering your rate of infection.
Florez contends that promoting correct behaviors at the bedside can be almost as difficult as demonstrating the value of an efficacious infection control program. We can have policies, we can pull them from the most recognized sources such as the CDC, but getting the bedside provider including the nurse, the physician and others to embrace the guidelines and actually practice those guidelines is a challenge, he says. Were not there 24/7 and we have to rely on the professionalism of our staff, including doctors and nurses, but its not always there. Education is one part, but buy-in is another. If I can truly sell them on the importance of those guidelines and how they have shown by repeated research to reduce infection, then hopefully I get their buy-in, because then you have a win-win situation.
Dealing with the aged and often frail population that comprises long-term care facilities presents its own issues from an infection control perspective. Infections are a fact of life in this environment, with more than 1.5 million occurring per year, which equates to approximately one to two per resident.2 Furthermore, it is estimated that about one-quarter of the hospital admissions that come from long-term care facilities are due to infections.
The nursing home is their home for many of them, Chinnes says. We try to balance issues such as isolation and determining which residents really need to stay in their rooms, and which ones can come out for group activities such as dining and recreational events for their socialization, which is just as important in the nursing home setting as their physical care.
They may be depressed or not eating, and part of their treatment plan may be to have them interact with other people and staff. These types of considerations may affect how infections are dealt with. We have different ways of isolating resistant organisms, for example, in long-term care, Chinnes continues. We may say, if theres a patient colonized with methicillin-resistant Staphylococcus aureus (MRSA) in the nose, well let him come out and mix with other people if good hygiene is used. However, if he has a large open would thats soaking through his dressing and has MRSA, then that resident may need to stay in his room.
Kassai explains that older patients may have more trouble with compliance as well. Dementia can be a significant challenge in long-term care, she says. Its very difficult to isolate somebody with dementia, because its very hard to make them understand what it means, and that presents a challenge.
You also have people with compromising conditions such as diabetes, some of them are on dialysis, and then you have rules and regulations in long-term care that really limit isolation you cant put a patient in isolation as easily in long-term care as in acute care because of their socialization needs, their therapy needs, their requirements for treatment that surround their placement in a long-term care facility.
Chinnes points out that there are many healthcare-associated infections in nursing homes as well. Much of the time, there may not be the diagnostic certainty such as in a hospital, she says. Many times doctors are not ordering labs or X-rays. If we tell them that the resident is having pain on voiding, the physician may just put the patient on an antibiotic. Thats the other side of the coin the high antimicrobial use in the nursing home without always knowing what were treating. Years ago, we used to see people in nursing homes without a lot of indwelling lines, but thats changing now. A lot of nursing home residents do have devices, and of course along with devices comes increased risk of infection.
Kassai notes that infection control responsibilities are often given to a nurse who may already have a lot on his or her plate, such as someone whose role involves education or quality, or the director of nursing. Many times its an assigned duty, she says. I think thats beginning to change, however; theyre beginning to see the need for someone who is trained in infection control vs. someone who just does the job. One of the things Joint Commission is emphasizing right now is communication between different levels of care, and one of the things that they want communicated is the resistant organisms and infection control-related issues, so that when a patient comes from acute care to long-term or vice versa, there is some communication about the types of infections theyve had treated, etc., because they want that to be part of the transfer process.
Long-term acute care describes a relatively new and emerging setting that ICPs should become familiar with, according to Kassai. These settings are basically acute care, but the patients come from hospitals, from other acute-care settings, and they are patients who have gone in for surgery or for some other medical condition, but have developed complications, she explains. It can be multi-system failure, dependence on a ventilator, wounds, etc., and they come to this type of facility for the purpose of being weaned off the ventilator, treating their wounds, or stabilizing them in general. They stay an average of 25 days, and it is acute care I want to stress that, but many times they come into this new setting colonized or infected with resistant organisms, and thats where communication is important.
Kassai says this type of environment can be beneficial in terms of helping patients to progress more rapidly than they might have been able to in a long-term care facility. Infection control must play a major role in order to promote this success, however. The (infection control) challenges there are basically the things that you do in acute care to emphasize good hand hygiene, establish contact isolation when indicated, and emphasize good aseptic technique.
Given the vast range of ambulatory settings that exist in todays healthcare world and the increasing numbers of patients who make use of them, transmission of infection is a serious concern. Specific challenges facing ambulatory environments include:
- Determining which infections to conduct surveillance for
- Deciding what definitions to use
- Establishing personnel to perform surveillance
- Determining to who the data will be reported
- Establishing a method for implementing necessary changes3
Ambulatory care can be anything from a prison to a doctors office to an endoscopy lab to a surgery center, says Chinnes. The thing to me that is so scary about ambulatory care is that you can have a very sick patient in the waiting area sitting right beside a relatively well patient. For example, a patient with chronic bronchitis, later diagnosed as TB, may be coughing and sitting next to the well infant awaiting outpatient surgery.
The chance of contracting an MDRO also seems to be increasing in non-acute settings, which is a significant concern for many. I think were beginning to see everything everywhere (in terms of resistant organisms), Kassai says. MRSA and VRE (vancomycinresistant Enterococcus faecium) cross the spectrum. Occasionally in some settings where they have ventilator units or respiratory units where there are patients on ventilators, you may see more gram-negative organisms, but that really varies from institution to institution. I think one of the issues today that is lending itself to more consistency across the healthcare spectrum is the fact that patients move from one type of facility to another.
When surgery is involved, establishing and maintaining low rates of infection depend upon adherence to standards. In your surgery centers, the biggest preventive strategy is good sterilization, good monitoring of sterilization, and good operative technique, Kassai says. Thats critical, because if all of those things skin preparation, preparation of the patient, operative technique, sterilization and disinfection, and follow up if all of that is done appropriately, the risk of infection is very low. Where you run into problems is when those things are not done correctly.
Dialysis centers are highly specialized and unique ambulatory environments that can run into infection problems very quickly if established guidelines are not followed. Many outbreaks have occurred in those settings due to deficiencies in basic infection control practices,
Chinnes explains. You might see things like bloodstream infections or what we call pyrogenic reactions after the dialysis starts, the patient spikes a high fever. You may see fistula and exit-site infections on some of the catheters; you can even see hepatitis B and C transferred from patient to patient, or patient to healthcare worker. We used to think the risk was low in the outpatient setting, but the literature is full of examples of outbreaks from things like contaminated fluids and multidose vials, or common waiting rooms where maybe someone with undiagnosed measles was right beside someone who had cancer. Lots of opportunities are there.
1. Friedman C, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. Association for Professionals in Infection Control and Epidemiology and Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol. 1999 Oct;20(10):695-705.
2. Vance J, Wilson KM. Getting a handle on infection control in long-term care. Caring for the Ages. September 2001, Vol. 2, No. 9, p. 22-27
3. Jarvis WR. Infection control and changing healthcare delivery systems. Emerg Infect Dis. 2001 Mar-Apr;7(2):170-3.