Preventing Infections in Long-Term Care
By Libby F. Chinnes, RN, BSN, CIC
Infection prevention in long-term care is a priority, especially with the expected increase in the elderly population in the Unites States during the next several decades. In fact, there are more patients in this country in long-term care than in acute care facilities. It is our duty to protect this susceptible population now and for years to come.
A Susceptible Population
The typical nursing home resident is 85 years of age and older, has multiple illnesses, is immunocompromised and is on multiple medications. Additionally, the resident may be confused and/or incontinent, and yet ambulatory and able to serve as a vector for illnesses such as tuberculosis and infectious diarrhea. The closed environment of the nursing home may lead to cross contamination and infections in a host whose care is now seemingly more complex as patients are discharged to the nursing home with the presence of IVs, tracheostomies, feeding tubes and urinary catheters. It is no wonder that infections are a major problem in long-term care.
A Snapshot of Reality
Several surveys have estimated the nosocomial infection rate (prevalence or incidence) to be 5 to 15 infections per 100 residents per month, 5 to 6 infections per 1000 resident days1 (roughly that of acute care facilities). The most frequent endemic infections in long-term care include: urinary tract infections; respiratory tract infections including upper tract infections such pharyngitis and sinusitis and lower tract infections such as bronchitis and pneumonia; skin and soft tissue infections; and gastrointestinal infections.2 Outbreaks have also occurred in this setting with Influenza A as one of the most common agents as well as gastrointestinal outbreaks and skin outbreaks such as scabies. Residents may also be colonized with antimicrobial drug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), but transmission is usually uncommon in a non-outbreak situation.
The long-term care setting is unique, however, in several aspects. The facility is "home" for most residents. Infection control must be balanced with the residents' need for socialization and mobility. Residents may also have great functional impairment as well as incontinence, confusion, or dementia. In addition, there is often diagnostic uncertainty with the elderly who may exhibit vague nonspecific symptoms such as confusion or low-grade fever rather than the classic clinical signs of infection. This, along with limited use of lab and radiological tests, often leads to inappropriate antibiotic use and may lead to drug-resistant organisms.
What's in Place?
In recent years, infection prevention and control programs have been established in most nursing homes. However, with fewer resources, long-term care infection control professionals (ICPs) may wear many other hats in terms of responsibilities and have little time devoted solely to infection control issues. In 1997, the Society of Healthcare Epidemiologists of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) published a position paper on infection control in long-term care facilities.3 This paper recommended that an oversight committee of the program be established (usually including participation of the ICP, administrator and medical director). According to this paper, the components of an infection control program in long-term care should include: surveillance, outbreak control, isolation and precautions, policies and procedures, education, resident health program, employee health program, antibiotic review, disease reporting and other functions such as quality improvement and safety.
Infection Control Program
There should be an active facility-wide program as noted above to assist in prevention and the spread of infection. The oversight committee should direct the activities of the ICP. The ICP should be assigned the responsibility to implement, monitor and evaluate the infection control program. The ICP must have the support of administration for resources, training and sufficient time to direct the program as well as written authority to institute control measures (such as isolation) in emergencies.
There should be an ongoing, concurrent system for collection of data on infections in the facility. At the very least, surveillance should be conducted weekly and data may be obtained primarily through communication with the staff. Walking rounds and staff-communication clipboards at the nurses' station may assist in this effort. Review of the patient's medical record with particular attention to cultures, treatments ordered and the progress notes may lead to clues of nosocomial infections. Surveillance data should be used to calculate infection rates, and the ICP should analyze the data for trends and unusual occurrences to report to the committee and staff. This data can be used for planning infection control activities, staff education, and to detect outbreaks.
As mentioned previously, surveillance data should be used to detect and prevent outbreaks in the institution. The facility should define written authority for intervention during an outbreak such as relocation of residents or restricting visitors during influenza season. Some states have written guidelines on outbreak control to assist the ICP.
Isolation and Precautions
The facility should have written policies and procedures on isolation and precautions which are monitored and reinforced with the staff periodically. The use of standard precautions and compliance with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard should be enforced. A variety of isolation practices may be used in the long-term care facility. The Centers for Disease Control and Prevention (CDC)'s combination of standard precautions and transmission-based precautions (airborne, contact and droplet precautions) may be used. Hand hygiene is also a critical part of isolation technique and prevention of the spread of infection. Additionally, of great importance are policies dealing with acceptance and transfers of residents with suspect or confirmed infectious diseases.
Policies and Procedures
There should be written infection control policies and procedures for all departments (physical therapy, housekeeping, etc.) as well as all services (pet therapy, beautician services, etc.). Of major concern should be policies and procedures for cleaning, disinfection and/or sterilization of patient care items between residents and the cleaning and disinfection of the resident's environment.
The ICP should be a resource for the staff and conduct inservice education at orientation and regularly thereafter. Topics could include findings from surveillance, regulatory requirements, infectious disease transmission, hand hygiene and isolation precautions, sharps injury prevention, etc.
Resident and Employee Health
Each resident should have an initial history, exam, immunizations as indicated and TB skin test (unless positive). Provisions should be made to maintain resident hygiene as well as policies and procedures to prevent such complications as urinary infections, pneumonia and pressure ulcers. In addition, new employees should be assessed initially and ongoing for health status. There should be policies on immunizations, exposures and work restrictions for sick staff.
ICPs should be involved with the important process of monitoring antibiotic resistance and antimicrobial review. In addition, infectious disease reporting to the health department and participating in safety efforts are equally as important. Infection control is a quality improvement effort in long-term care.
Libby Flanders Chinnes is an infection control consultant for IC Solutions in Mount Pleasant, S.C. She can be reached by phone at (843) 849-6027, by fax at (843) 881-3714, or by email at [email protected].