Infection Prevention in Outpatient and LTC Settings

Pathogenic organisms are like international travelers with unrestricted passports; they can flourish everywhere acute-care, ambulatory care and long-term care settings.

As the boundaries between all segments of the continuum of care (inpatient, ambulatory, long term) continue to blur, the priorities for each are becoming more closely aligned, says Sue Barnes, RN, BSN, CIC, national leader of infection prevention and control/patient safety at Kaiser Permanente. For this year, I would say that the most problematic pathogen is Clostridium difficile, due to the increasing virulence, incidence and associated morbidity and mortality. This pathogen is directly related to antibiotic use and contaminated environmental surfaces which are present in all three care settings.

Barnes says there are several urgent infection prevention-related issues at work in these three care settings; the first is adequate resourcing for infection prevention in all segments of the care continuum, especially this year with the new burden of mandatory reporting of infection rates. Although this will help the drive to zero infections eventually, in the short term is only serving to divert already constrained infection control staff from infection prevention activities, in order to create reports, Barnes says. The second is environmental cleaning and disinfection, specifically supporting reducing Clostridium difficile infection transmission. The third is finding a way to automate infection surveillance, which is directly related to the aforementioned lack of staffing and resources.

Barnes says that no matter the care setting, there are several critical best practices relating to infection prevention that are appropriate: hand hygiene and appropriate glove use; environmental cleaning and disinfection; and respiratory etiquette (covering your cough with mask, tissue and cleaning hands frequently).

We take a look at infection prevention issues in outpatient care and long-term care facilities.

Outpatient Care

Infection prevention should move to center stage in this setting because more surgical procedures are being handled in ambulatory care facilities than ever before. According to a new study, Ambulatory Surgery in the United States, 2006, from the Centers for Disease Control and Prevention (CDC) the number of outpatient surgery visits in the United States increased from 20.8 million visits in 1996 to 34.7 million visits in 2006.

Campos-Outcalt (2004) notes, It is easy to overlook the potential for spreading infectious diseases in the outpatient setting. Relying on healthcare workers to practice good hygiene is unlikely to be enough. This public health battle must employ a comprehensive plan for clinic design, involving staff in setting and enforcing policies, and repeatedly emphasizing the importance of good hygiene. Campos-Outcalt encourages outpatient facilities to institute and enforce policies on respiratory hygiene and hand hygiene, as well as immunize all staff members, and be on alert for potentially contagious patients.

A number of high-profile outbreaks of hepatitis have grabbed headlines in recent years, including breaches in infection control techniques and unsafe injection practices that exposed more than 40,000 patients to hepatitis at an endoscopy center in Las Vegas in 2007. Unsafe injection practices have also been cited at freestanding centers in Nebraska, New York, Michigan and North Carolina.

In the last decade, more than 60,000 patients in the United States were asked to get tested for hepatitis B virus (HBV) and hepatitis C virus (HCV) because healthcare professionals in settings outside hospitals failed to follow basic infection control practices, according to a study by the CDC. This first full review of all the CDC investigations over the past 10 years of healthcare-associated viral hepatitis outbreaks appeared in the Jan. 6, 2009 issue of Annals of Internal Medicine.

This report is a wake-up call, says John Ward, MD, director of CDCs Division of Viral Hepatitis. Thousands of patients are needlessly exposed to viral hepatitis and other preventable diseases in the very places where they should feel protected. No patient should go to their doctor for healthcare only to leave with a life-threatening disease.

Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC), in a prepared statement issued earlier this year, observed, APIC is very concerned by the mounting number of cases in which clinicians in ambulatory care settings failed to follow safe injection practices, causing outbreaks of serious infections and endangering the lives of patients. These outbreaks were preventable and should never have occurred. Consumers seek healthcare services to get better and should not be exposed to unnecessary risk.

In the United States, transmission of HBV and HCV while receiving healthcare has been considered uncommon. However, a review of CDC outbreak information revealed a total of 33 identified outbreaks outside of hospitals in 15 states, during the past decade: 12 in outpatient clinics, six in hemodialysis centers and 15 in long-term care (LTC) facilities, resulting in 450 people acquiring HBV or HCV infection. Patients were exposed to these potentially deadly diseases because healthcare personnel failed to follow basic infection control procedures and aseptic technique in injection safety. Reuse of syringes and blood-contamination of medications, equipment and devices were identified as common factors in these outbreaks.

More and more patients in the United States receive their healthcare in outpatient settings, says Denise Cardo, MD, director of CDCs Division of Healthcare Quality Promotion. To protect patients, infection control training, professional oversight, licensing, innovative engineering controls and public awareness are needed in these healthcare settings.

CDC officials say the report shows the need for ongoing professional education for healthcare providers, as well as consistent state oversight in detecting and preventing the transmission of bloodborne pathogens in healthcare settings.

Warye advises, With an increasing amount of care being delivered in outpatient settings, more patients will be put at risk unless clinicians are adequately educated and consistently adhere to infection prevention measures. Clinics should also be concerned about new and more virulent pathogens, such as MRSA, which can be transmitted in outpatient settings and take a hard look at how they are addressing infection prevention overall.

The outbreak in Las Vegas was an opportunity for every ASC to review their policies on IV medication administration as well as all infection control policies, says Carol Imes, RN, MPA, CNOR, director of nursing at Mentor Surgery Center in Mentor, Ohio. I used this situation to educate my staff on best practices as well as unsafe practices. The reality is that ASCs have a very low infection rate less than 1 percent.

Having said that, however, Imes cautions, With the rise in drug-resistant infections, I think that ASCs will see more infections. We are accepting higher-risk patients with obesity, diabetes, cardiovascular problems including hypertension and circulatory problems who may be more prone to infections, and we never know exactly to what environment we are sending our patients. We have some advantages in ASCs that include much shorter length of stay and contact with fewer people who might contribute to infections. I also think that ASCs take infections very seriously and analyze each case thoroughly to see if there are trends or if changes are needed in protocols. New required quality measures will reinforce what ASCs already do. Focus on administering IV antibiotics within one hour of incision may help decrease infections, but that is not always easy to do. Handwashing is one key to lowering infections.

Imes encourages ASCs to pay close attention to environmental cleaning and follow the 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities from the Centers for Disease Control and Prevention (CDC). I just printed these guidelines and I will be reading them over the next couple of weeks. I hope that they will not negate my feelings on some sacred cows that we have buried many years ago (e.g., we do not require shoe covers; we do not wash our OR floors after every case unless there is blood or body fluids on it; and allowing staff to wash their own scrubs). We have lacked sound scientific evidence on many of our surgical practices, and I have found no increase in our infection rates after eliminating these sacred cows.

The CDC says it is working to address the patient safety challenge in the outpatient setting through a number of efforts, including:

Improving viral hepatitis surveillance, case investigation and outbreak response, such as support for health departments to thoroughly investigate all individuals identified to have HBV or HCV infection

Strengthening the capacity of state and local viral hepatitis prevention programs

Augmenting the CDCs National Healthcare Safety Network, the national surveillance system for tracking healthcare-associated infections, to collect outpatient setting information

Partnering with the Hepatitis Outbreaks National Organization for Reform (HONOReform), a patient advocacy foundation, to create patient and provider education materials

Continued improvement of injection safety practices through educational outreach efforts with professional nursing and anesthesiology organizations;

Working with partners in the dialysis, diabetes and long-term care communities to promote safe care practices

Working with regulators and professional societies to strengthen licensure and accreditation processes with emphasis on safe injection practices

Long-Term Care

More than 1.5 million individuals reside in approximately 15,000 nursing homes in the U.S. currently, and that number is anticipated to grow significantly; the Administration on Agings statistics predict that the population of those age 85 and older is expected to double by 2030. Not only will there be more long-term-care facility (LTCF) residents, but the acuity of illness of these residents is expected to increase.

The SHEA/APIC guideline on infection control in LTC observes, LTCF residents have a risk of developing healthcare-associated infection (HAI) that approaches that seen in acute-care hospital patients. With 1 of every 4 persons who reach the age of 65 expecting to spend part of his or her life in a nursing home, there is more need than ever before to curtail and eliminate infections in this population; however, 1.6 million to 3.8 million infections still occur annually in LTCFs.

The SHEA/APIC guideline on infection control in LTC notes, In addition to infections that are largely endemic, such as urinary tract infections (UTIs) and lower respiratory tract infections (LRTIs), outbreaks of respiratory and gastrointestinal (GI) infections are also common. The overall infection rate in LTCFs for endemic infections ranges from 1.8 to 13.5 infections per 1,000 resident-care days. For epidemics, good estimates are difficult to ascertain, but the literature suggests that several thousand outbreaks may occur in U.S. LTCFs each year. The wide ranges of infections and resulting mortality and costs illustrate the challenge in understanding the epidemiology of infections and their impact in LTCFs. There are currently little data and no national surveillance systems for LTCF infections; the estimates have been calculated based on research studies and outbreak reports from the medical literature.

While acute-care hospitals have their share of immuno-compromised patients, LTCF residents have diminished immune system response and can be easy targets for pneumonia, catheter-associated urinary tract infections, and age-related functional impairments (such as incontinence and immobility issues) that can affect their personal hand hygiene. Utilization of medical devices in LTCFs can contribute to infections in LTCF patients; for example, while the use of urinary catheters in LTCF residents has decreased in recent years, use remains around 5 percent, and other invasive devices such as central venous catheters, mechanical ventilators and enteral feeding tubes increase the likelihood of a device-associated infection.

Studies have demonstrated that the rate of deaths in LTCF residents with infections ranges from 0.04 to 0.71 per 1,000 resident-days, with pneumonia being the leading cause of death. The same studies have indicated that infections are a leading reason for hospital transfer of LTCF residents, and the resulting hospital costs range from $673 million to $2 billion annually.

The SHEA/APIC guideline on infection control in LTC outlines some specific infections found in the LTCF:

UTIs

Studies have shown that UTIs are the most common infection in LTCFs, and that prevalence of indwelling urethral catheters in the LTCF is approximately 7 percent to 10 percent. Residents with indwelling urinary catheters in the LTCF are usually colonized with bacteria mostly due to biofilm on the catheter. The SHEA/APIC guideline on infection control in LTC states, Guidelines for prevention of catheter-associated UTIs in hospitalized patients are generally applicable to catheterized residents in LTCFs. Recommended measures include limiting use of catheters, insertion of catheters aseptically by trained personnel, use of as small diameter a catheter as possible, handwashing before and after catheter manipulation, maintenance of a closed catheter system, avoiding irrigation unless the catheter is obstructed, keeping the collecting bag below the bladder, and maintaining good hydration in residents.

Respiratory infections

Viral upper respiratory infections (URIs) such as influenza, respiratory syncytial virus (RSV), parainfluenza, coronavirus, rhinoviruses and adenoviruses that generally are mild in other populations can trigger significant disease in the institutionalized elderly patient due to their impaired immune systems. Pneumonia, a lower respiratory tract infection, is the second most common cause of infection among LTCF residents, with an incidence ranging from 0.3 to 2.5 episodes per 1,000 resident care-days and is the leading cause of death from infections in this setting. Tuberculosis also can cause extensive outbreaks in LTCFs, with a potential to spread in the community. Influenza, another significant threat to LTCF residents, has clinical attack rates ranging from 25 percent to 70 percent, with case fatality rates averaging more than 10 percent, according to studies. Vaccination of LTCF residents can vary, although in 2005, the Centers for Medicare & Medicaid Services (CMS) published a final rule requiring LTCFs to offer annually to each resident immunization against influenza and to offer lifetime immunization against pneumococcal disease. LTCFs are required to ensure every resident is educated on the benefits and potential side effects of the immunizations prior to their administration. Influenza vaccination rates for a facility are now publicly reported on the CMS Web site http://www.medicare.gov/NHCompare/home.asp.

Skin/Soft-Tissue Infections and Infestations

Decubitus ulcers (commonly called pressure ulcers) are present in up to 20 percent of LTCF residents; ulcers that are infected are frequently deep soft-tissue infections that require costly and aggressive medical and surgical therapy. Scabies infestations are also common in LTCF patients.

As in acute-care, outbreaks take on many personalities, so to speak. According to the SHEA/APIC guideline on infection control in LTC, outbreaks in LTCFs can be sporadic in nature, caused by colonizing pathogenic organisms with relatively low virulence; or they can occur explosively with many clinical cases appearing within a few days or may, for example, involve an unusual clustering of MRSA clinical isolates on a single nursing unit over several months. On the other hand, a case of MRSA infection may follow a prolonged period of asymptomatic nasal colonization after an aspiration event or development of a necrotic wound.

Outbreaks in LTCFs account for about 15 percent of reported epidemics; studies point to the clustering of UTIs, diarrhea, skin and soft tissue infection, conjunctivitis and antibiotic-resistant bacteriuria, as well as outbreaks caused by E. coli, group A streptococci, Clostridium difficile, Salmonella spp, Chlamydia pneumoniae, Legionella spp, hepatitis B, viral conjunctivitis and gastrointestinal viruses (LTCFs accounted for roughly 2 percent of all foodborne disease outbreaks reported to the CDC from 1975 to 1987 and 19 percent of outbreak-associated deaths.

The SHEA/APIC guideline on infection control in LTC observes, Ongoing surveillance is required to detect epidemic clustering of transmissible, virulent infections. Outbreaks must be anticipated. Ideally, infection control surveillance and practices should be the responsibility of frontline staff as well as infection control staff. The guideline authors are quick to point out, however, that LTCFs have far fewer infection preventionists that acute-care facilities and that LTCF-based infection preventionists are more likely to assume non-infection control functions (including employee health, staff education and development, and quality improvement) than their acute-care colleagues, regardless of bed size. Some studies have shown that LTCF-based infection preventionists are less likely to receive additional formal training in infection prevention and control compared to acute-care infection preventionists.

A study in Maryland actually triggered a state proposal that at least one infection preventionist from each LTCF be formally trained in infection control. The SHEA/APIC guideline on infection control in LTC adds, While the time spent on infection control activities appears to have increased significantly from 36 to 48 hours per month in the 1990s to 90 to 160 hours per month in 2005, the ICP continues to have other duties such as general duty nursing, nursing supervision, in-service education, employee health, and quality assurance. Both SHEA and APIC have recommended that non-hospital facilities including LTCFs provide adequate resources in terms of personnel, education, and materials to infection preventionists to fulfill their functions.

In Canada, experts are calling for one full-time formally trained infection preventionist per 150 to 250 long-term beds. This comes at a time when a new Queens University study shows that infection prevention and control resources and programming in Canadian LTCFs fall short of recommended standards. Led by community health and epidemiology professor Dick Zoutman, the national survey of 488 facilities is the first comprehensive examination of these resources and programs in nearly 20 years.

Findings from this study include:

The average number of full-time equivalent infection control professionals (ICPs) per 250 beds was 0.6, compared to the recommended 1.0.

Only 8 percent of ICPs were certified by the Certification Board of Infection Control and Epidemiology.

Only one-fifth of LTCFs had physicians or doctoral-level professions providing service to the infection control program.

Eighty-two percent of LTCFs infection prevention and control programs are conducting less than 80 percent of expert-suggested surveillance activities to identify infections.

Half (51 percent) of LTCFs are conducting less than 80 percent of suggested control activities to prevent the spread of infections.

Even as many LTCFs in the U.S. struggle to provide designated infection preventionists on their staffs, they fly in the face of the Omnibus Budget Reconciliation Act of 1987 (OBRA) that requires them to have an infection control program. In addition, CMS requires facilities accepting Medicare and/or Medicaid residents to have a comprehensive infection control program that includes surveillance of infections, as well as implementation of methods for preventing the spread of infections including use of appropriate isolation measures, employee health protocols, hand hygiene practices, and appropriate handling, processing, and storage of linens. Interpretive guidelines for surveyors further discuss definitions of infection, risk assessment, outbreak management and control, measures for preventing specific infections, staff orientation, antibiotic monitoring, sanitation, and assessment of compliance with infection control policies.

The SHEA/APIC guideline on infection control in LTC observes, Much remains to be learned about resident and LTCF factors correlated with HAIs. There is evidence that institutional factors such as nurse turnover, staffing levels, prevalence of Medicare recipients, rates of hospital transfer for infection, intensity of medical services, and family visitation rates are associated with incidence of HAI in the LTC setting.

Disinfection Best Practices

Ken Palmero, president of Palmero Health Care, specializes in disinfectants and for 37 years has promoted the development of standards that he believes should be applied to all disinfectants. He answered some questions from ICT about disinfection best practices.

ICT: In regard to surface disinfecting, what are some of the most commonly-overlooked areas in healthcare settings?

Cross contamination is a major issue due to the lack of efficacious disinfectants and barriers. Healthcare managers need to adopt a clean room approach to saving lives, similar to those used in producing computer chips.

ICT: What aspects of surface disinfection should healthcare workers most keep in mind?

Most disinfectants evaporation time is shorter than its kill time, so most pathogens are not killed. Since disinfectants are the first line of defense against deadly organisms, if it evaporates before killing, you have little or no real protection. It is a shame administrators and infection control specialists never take the time to read the back label. If they did, theyd be aware of this simple, alarming fact. Time a disinfectants evap rate by putting it on a surface and watching it disappear; a disinfectants kill time should be shorter than its evaporation rate.

ICT: Do the principles of surface disinfection range dramatically in various healthcare models (ambulatory surgery centers vs. hospitals, for example), or should all facilities be disinfected in similar ways?

You need equal protection wherever deadly organisms can be found. Thats true of all healthcare models. Hospitals, of course, are the site of more deadly transference of infection and additional precautions should be taken.

Reported by Michelle Beaver

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