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Acute-Care, Long-Term Care, and Ambulatory Care
By Kris Ellis
The delivery of healthcare in the UnitedStates has undergone drastic changes over the past couple of decades. From thedramatic increase in procedures performed in outpatient settings to theexplosive growth of long-term and home-based care, the landscape has beenfundamentally altered.
The effort to control infection, as a vital component ofpatient care, must not only adapt to these changes, but also must be proactivein protecting healthcare workers and patients alike from an ever-expanding rangeof 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 controlpractitioners (ICPs) is in great need.
Although each healthcare setting encompasses a unique set ofcircumstances that must be taken into consideration, many basic infectioncontrol principles can and should be applied to any environment.
The broad, general principles that apply everywhere arehand hygiene, aseptic technique, and environmental cleanliness, says LibbyChinnes, RN, BSN, CIC, president of Mount Pleasant, S.C.-based IC Solutions,LLC. Sometimes we do more in the perioperative setting withcleaning the environment; but cleaning the nursing home room and the acute-carehospital room should be the same. Sometimes we might use different disinfectants in the home,but were still disinfecting those environmental surfaces and also pieces ofequipment for use on patients.
The one that is most consistent across every setting ishand hygiene, says Marie Kassai, RN, MPH, CIC, infection control professionalfor Kindred Hospital New Jersey. That crosses every setting that there is,both from the physician, patient, and healthcare worker standpoint. Kassaialso mentions adherence to universal/standard precautions as a fundamentalconcern. Those are the two most important things and probably next would beisolation, and isolation varies in each of those settings because of thedifferent patient populations that they have.
Christopher Florez, BS, CIC, director of infection control forSan Antonio-based St. Lukes Baptist Hospital, notes that accreditationrequirements should be considered in evaluating principles; specifically, thosefrom the Joint Commission on Accreditation of Healthcare Facilities (JCAHO). Hesays hand hygiene is, of course, prominent in this respect, among other things.Theres also a paradigm shift to doing patient tracer methodology in thatthere is a key focus on communication in the healthcare setting, he says. Theyrereally looking at communication along the continuum of care for the stay of thepatient.
In terms of setting up an effective infection control program,Chinnes points to a joint report from the Association for Professionals inInfection Control and Epidemiology (APIC) and the Society for HealthcareEpidemiology of America.1 The report talks about some of the differences inout-of-hospital settings, she says. However, some of the similarities insetting up an infection control program in any setting are that the goals for aninfection control program are probably the same. There are three goals: protectthe patient first, protect healthcare workers and visitors (a close second), anddo it in as timely and cost effective a manner as you possibly can.
The report identifies the principal functions of infectioncontrol and epidemiology as:
Chinnes explainsthat the policies and procedures should be practical, science-based wherepossible, and monitored for compliance. Then we need to see if they arecurrent with the literature, practical enough that the staff can follow through,and also that the staff are indeed following them, she says. Directintervention to prevent infections means being proactive, as Chinnes points out.We usually dont wait until we have an outbreak; were interveningroutinely, whether its in the nursing home, the patients home, or thesurgery 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 encountera broad range of settings and caregivers. As people are seen more and more inoutpatient and home settings, now were training patients and theircaretakers, who may or may not be medically oriented, Chinnes says.
As the traditional environment for infection control programsand practices, ICPs are intimately familiar with many of the issues that mayarise and the guidelines and standards surrounding acute-care facilities. However, there are always plenty of emerging developments thatrequire ICPs precious time and resources.
Florez again points to adherence to JCAHO standards, and thefocus on patient tracer methodology. Once a patient is identified in thehospital as having an infection or the requirement for isolation, youve gotto show some documentation for that, and then its got to be communicated,he says. What weve found in working with some JCAHO consultants is thatyou, as the ICP, will put an entry into the computer and then do your follow-upsas needed, you put some form of communication in there, and then its got tobe followed by the practitioner at the bedside. Part of that is getting theinformation from caregiver to caregiver in a report, but it doesnt alwayshappen, and that can be a showstopper for a hospital when it comes to the continuum of care andcommunication. These are things that are starting to really shift in theinfection control realm.
Emerging infectious diseases also constitute a new risk thatmust be reckoned with. One of the most important things you have to do (inacute care) is patient assessment, Kassai says. Especially in the ER, itsreally critical to assess patients for any possible type of infection, andidentify those infections that trigger additional preventive measures such as TB(tuberculosis) or SARS (severe acute respiratory syndrome), or something thatrequires that the patient be put in isolation.
Chinnes notes that with a sicker population, a host ofresistant organisms, and patients who are having many more invasive procedures,the infection control effort is made even more challenging. Most of us arealso trying to target our scarce resources because we cant follow everythingand everybody every day, she says. We have to target the priority areas inour own facilities, and that usually involves the people with devices, like thepeople on vents for pneumonias, and the people with central lines forbacteremias. 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 aboutthat. There are a lot of preventative measures we can take and monitor to try tocontrol those infections.
Chinnes also points out that many patients in acute caresettings have invasive lines, may be immuno-suppressed, and often have multi-drugresistant organisms (MDROs). Acute care is also constantly challenged withproper disinfection and sterilization of patient care equipment, includingscopes, she continues. Of course, acute care is also revving up for potentialbioterrorism. A part of their disaster plan, and a mandate from JointCommission, is learning how to set up practices in terms of how we would dealwith a rapid influx of infectious disease patients. What do we need to do? Do weneed to isolate them or need more ventilators or special medicine? Do we knowhow to triage them and get them through our big hospital systems?
The only way to tackle this potentially monumental issue isextensive planning, according to Florez. Everybody has to be in synch withwhats going on you cant just say, Youre going to do this, youregoing to do that, and its all going to fall into place, because it willnot happen that way. Any time you have a disaster or any type of emergencysituation, you can almost be assured that somethings not going to go right.
Florez says a large part of the planning effort involvesestablishing capable leaders. He likens effective leadership in this type ofsituation to a military command center. Whoever runs that command center hasto 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 placewho are experts. In terms of infection prevention, we know different modes oftransmission of infectious diseases, but the key for that type of event ishaving a system in place to identify your index cases and then track thosepeople as they start to hit the ERs and hospital settings. Also, understanding the mode of transmission and being able tospeak intelligently as to how you can prevent further exposure to other citizensin 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 inacute-care settings, many are faced with the task of quantitatively justifyingthe need for an infection control program and the resources necessary tomaintain it. We are not revenue generators we are cost avoiders, andgetting the board of directors to understand that can be challenging, saysFlorez. So how do you measure the worth of the program? The onlyway you can do that is to put together a solid infection prevention program andshow them the potential cost savings; the costs that you can avoid with theprevention of infection or lowering your rate of infection.
Florez contends that promoting correct behaviors at thebedside can be almost as difficult as demonstrating the value of an efficaciousinfection control program. We can have policies, we can pull them from themost recognized sources such as the CDC, but getting the bedside provider including the nurse, the physician and others to embrace the guidelines andactually practice those guidelines is a challenge, he says. Were not there 24/7 and we have to rely on theprofessionalism of our staff, including doctors and nurses, but its notalways there. Education is one part, but buy-in is another. If I can truly sellthem on the importance of those guidelines and how they have shown by repeatedresearch to reduce infection, then hopefully I get their buy-in, because thenyou have a win-win situation.
Dealing with the aged and often frail population thatcomprises long-term care facilities presents its own issues from an infectioncontrol perspective. Infections are a fact of life in this environment, withmore than 1.5 million occurring per year, which equates to approximately one totwo per resident.2 Furthermore, it is estimated that about one-quarter of thehospital admissions that come from long-term care facilities are due toinfections.
The nursing home is their home for many of them,Chinnes says. We try to balance issues such as isolation and determiningwhich residents really need to stay in their rooms, and which ones can come outfor group activities such as dining and recreational events for theirsocialization, which is just as important in the nursing home setting as theirphysical care.
They may be depressed or not eating, and part of theirtreatment plan may be to have them interact with other people and staff. These types of considerations may affect how infections aredealt with. We have different ways of isolating resistant organisms, forexample, in long-term care, Chinnes continues. We may say, if theres a patient colonized withmethicillin-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 andhas MRSA, then that resident may need to stay in his room.
Kassai explains that older patients may have more trouble withcompliance as well. Dementia can be a significant challenge in long-term care,she says. Its very difficult to isolate somebody with dementia, because itsvery hard to make them understand what it means, and that presents a challenge.
You also have people with compromising conditions such asdiabetes, some of them are on dialysis, and then you have rules and regulationsin long-term care that really limit isolation you cant put a patient inisolation as easily in long-term care as in acute care because of theirsocialization needs, their therapy needs, their requirements for treatment thatsurround their placement in a long-term care facility.
Chinnes points out that there are many healthcare-associatedinfections in nursing homes as well. Much of the time, there may not be thediagnostic certainty such as in a hospital, she says. Many times doctorsare not ordering labs or X-rays. If we tell them that the resident is havingpain on voiding, the physician may just put the patient on an antibiotic. Thatsthe other side of the coin the high antimicrobial use in the nursing homewithout always knowing what were treating. Years ago, we used to see peoplein nursing homes without a lot of indwelling lines, but thats changing now. Alot of nursing home residents do have devices, and of course along with devicescomes increased risk of infection.
Kassai notes that infection control responsibilities are oftengiven to a nurse who may already have a lot on his or her plate, such as someonewhose role involves education or quality, or the director of nursing. Manytimes its an assigned duty, she says. I think thats beginning tochange, however; theyre beginning to see the need for someone who is trainedin infection control vs. someone who just does the job. One of the things JointCommission is emphasizing right now is communication between different levels ofcare, and one of the things that they want communicated is the resistantorganisms and infection control-related issues, so that when a patient comesfrom acute care to long-term or vice versa, there is some communication about thetypes of infections theyve had treated, etc., because they want that to bepart of the transfer process.
Long-term acute care describes a relatively new and emergingsetting that ICPs should become familiar with, according to Kassai. These settings are basically acute care, but the patientscome from hospitals, from other acute-care settings, and they are patients whohave gone in for surgery or for some other medical condition, but have developedcomplications, she explains. It can be multi-system failure, dependence ona ventilator, wounds, etc., and they come to this type of facility for thepurpose of being weaned off the ventilator, treating their wounds, orstabilizing them in general. They stay an average of 25 days, and it is acutecare I want to stress that, but many times they come into this new settingcolonized or infected with resistant organisms, and thats where communicationis important.
Kassai says this type of environment can be beneficial interms of helping patients to progress more rapidly than they might have beenable to in a long-term care facility. Infection control must play a major role in order to promotethis success, however. The (infection control) challenges there are basicallythe things that you do in acute care to emphasize good hand hygiene,establish contact isolation when indicated, and emphasize good aseptictechnique.
Given the vast range of ambulatory settings that exist intodays healthcare world and the increasing numbers of patients who make use of them,transmission of infection is a serious concern. Specific challenges facingambulatory environments include:
Ambulatory care can be anything from a prison to a doctorsoffice to an endoscopy lab to a surgery center, says Chinnes. The thing tome that is so scary about ambulatory care is that you can have a very sickpatient in the waiting area sitting right beside a relatively well patient. Forexample, a patient with chronic bronchitis, later diagnosed as TB, may becoughing and sitting next to the well infant awaiting outpatient surgery.
The chance of contracting an MDRO also seems to be increasingin non-acute settings, which is a significant concern for many. I think were beginning to see everything everywhere (interms of resistant organisms), Kassai says. MRSA and VRE (vancomycinresistant Enterococcusfaecium) cross the spectrum. Occasionally in somesettings where they have ventilator units or respiratory units where there arepatients on ventilators, you may see more gram-negative organisms, but thatreally varies from institution to institution. I think one of the issues today that is lending itself to moreconsistency across the healthcare spectrum is the fact that patients move fromone type of facility to another.
When surgery is involved, establishing and maintaining lowrates of infection depend upon adherence to standards. In your surgerycenters, the biggest preventive strategy is good sterilization, good monitoringof sterilization, and good operative technique, Kassai says. Thatscritical, because if all of those things skin preparation, preparation ofthe 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 ambulatoryenvironments that can run into infection problems very quickly if establishedguidelines are not followed. Many outbreaks have occurred in those settingsdue to deficiencies in basic infection control practices,
Chinnes explains. You might see things like bloodstreaminfections or what we call pyrogenic reactions after the dialysis starts,the patient spikes a high fever. You may see fistula and exit-site infections onsome of the catheters; you can even see hepatitis B and C transferred frompatient to patient, or patient to healthcare worker. We used to think the riskwas low in the outpatient setting, but the literature is full of examples ofoutbreaks from things like contaminated fluids and multidose vials, or commonwaiting rooms where maybe someone with undiagnosed measles was right besidesomeone who had cancer. Lots of opportunities are there.
1. Friedman C, et al. Requirements for infrastructure andessential activities of infection control and epidemiology in out-of-hospitalsettings: a consensus panel report. Association for Professionals in InfectionControl and Epidemiology and Society for Healthcare Epidemiology of America. InfectControl Hosp Epidemiol. 1999 Oct;20(10):695-705.
2. Vance J, Wilson KM. Getting a handle on infection controlin long-term care. Caring for the Ages. September2001, Vol. 2, No. 9, p. 22-27
3. Jarvis WR. Infection control and changing healthcaredelivery systems. Emerg Infect Dis.2001 Mar-Apr;7(2):170-3.