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By Libby F. Chinnes, RN, BSN, CIC
Infectionprevention in long-term care is a priority, especially with the expectedincrease in the elderly population in the Unites States during the next severaldecades. In fact, there are more patients in this country in long-term care thanin acute care facilities. It is our duty to protect this susceptible populationnow and for years to come.
A Susceptible Population
The typical nursing home resident is 85 years of age and older, has multipleillnesses, is immunocompromised and is on multiple medications. Additionally,the resident may be confused and/or incontinent, and yet ambulatory and able toserve as a vector for illnesses such as tuberculosis and infectious diarrhea.The closed environment of the nursing home may lead to cross contamination andinfections in a host whose care is now seemingly more complex as patients aredischarged to the nursing home with the presence of IVs, tracheostomies, feedingtubes and urinary catheters. It is no wonder that infections are a major problemin long-term care.
A Snapshot of Reality
Several surveys have estimated the nosocomial infection rate (prevalence orincidence) to be 5 to 15 infections per 100 residents per month, 5 to 6infections per 1000 resident days1 (roughly that of acute carefacilities). The most frequent endemic infections in long-term care include:urinary tract infections; respiratory tract infections including upper tractinfections such pharyngitis and sinusitis and lower tract infections such asbronchitis and pneumonia; skin and soft tissue infections; and gastrointestinalinfections.2 Outbreaks have also occurred in this setting withInfluenza A as one of the most common agents as well as gastrointestinaloutbreaks and skin outbreaks such as scabies. Residents may also be colonizedwith antimicrobial drug-resistant organisms, such as methicillin-resistant Staphylococcusaureus (MRSA) and vancomycin-resistant enterococcus (VRE), but transmissionis usually uncommon in a non-outbreak situation.
The long-term care setting is unique, however, in several aspects. Thefacility is "home" for most residents. Infection control must bebalanced with the residents' need for socialization and mobility. Residents mayalso have great functional impairment as well as incontinence, confusion, ordementia. In addition, there is often diagnostic uncertainty with the elderlywho may exhibit vague nonspecific symptoms such as confusion or low-grade feverrather than the classic clinical signs of infection. This, along with limiteduse of lab and radiological tests, often leads to inappropriate antibiotic useand may lead to drug-resistant organisms.
What's in Place?
In recent years, infection prevention and control programs have beenestablished in most nursing homes. However, with fewer resources, long-term careinfection control professionals (ICPs) may wear many other hats in terms ofresponsibilities and have little time devoted solely to infection controlissues. In 1997, the Society of Healthcare Epidemiologists of America (SHEA) andthe Association for Professionals in Infection Control and Epidemiology (APIC)published a position paper on infection control in long-term care facilities.3This paper recommended that an oversight committee of the program be established(usually including participation of the ICP, administrator and medicaldirector). According to this paper, the components of an infection controlprogram in long-term care should include: surveillance, outbreak control,isolation and precautions, policies and procedures, education, resident healthprogram, employee health program, antibiotic review, disease reporting and otherfunctions such as quality improvement and safety.
Infection Control Program
There should be an active facility-wide program as noted above to assist inprevention and the spread of infection. The oversight committee should directthe activities of the ICP. The ICP should be assigned the responsibility toimplement, monitor and evaluate the infection control program. The ICP must havethe support of administration for resources, training and sufficient time todirect 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 oninfections in the facility. At the very least, surveillance should be conductedweekly and data may be obtained primarily through communication with the staff.Walking rounds and staff-communication clipboards at the nurses' station mayassist in this effort. Review of the patient's medical record with particularattention to cultures, treatments ordered and the progress notes may lead toclues of nosocomial infections. Surveillance data should be used to calculateinfection rates, and the ICP should analyze the data for trends and unusualoccurrences to report to the committee and staff. This data can be used forplanning infection control activities, staff education, and to detect outbreaks.
As mentioned previously, surveillance data should be used to detect andprevent outbreaks in the institution. The facility should define writtenauthority for intervention during an outbreak such as relocation of residents orrestricting visitors during influenza season. Some states have writtenguidelines on outbreak control to assist the ICP.
Isolation and Precautions
The facility should have written policies and procedures on isolation andprecautions which are monitored and reinforced with the staff periodically. Theuse of standard precautions and compliance with the Occupational Safety andHealth Administration (OSHA) Bloodborne Pathogen Standard should be enforced. Avariety of isolation practices may be used in the long-term care facility. TheCenters for Disease Control and Prevention (CDC)'s combination of standardprecautions and transmission-based precautions (airborne, contact and dropletprecautions) may be used. Hand hygiene is also a critical part of isolationtechnique and prevention of the spread of infection. Additionally, of greatimportance are policies dealing with acceptance and transfers of residents withsuspect or confirmed infectious diseases.
Policies and Procedures
There should be written infection control policies and procedures for alldepartments (physical therapy, housekeeping, etc.) as well as all services (pettherapy, beautician services, etc.). Of major concern should be policies andprocedures for cleaning, disinfection and/or sterilization of patient care itemsbetween residents and the cleaning and disinfection of the resident'senvironment.
The ICP should be a resource for the staff and conduct inservice education atorientation and regularly thereafter. Topics could include findings fromsurveillance, regulatory requirements, infectious disease transmission, handhygiene and isolation precautions, sharps injury prevention, etc.
Resident and Employee Health
Each resident should have an initial history, exam, immunizations asindicated and TB skin test (unless positive). Provisions should be made tomaintain resident hygiene as well as policies and procedures to prevent suchcomplications as urinary infections, pneumonia and pressure ulcers. In addition,new employees should be assessed initially and ongoing for health status. Thereshould be policies on immunizations, exposures and work restrictions for sickstaff.
ICPs should be involved with the important process of monitoring antibioticresistance and antimicrobial review. In addition, infectious disease reportingto the health department and participating in safety efforts are equally asimportant. Infection control is a quality improvement effort in long-term care.
Libby Flanders Chinnes is an infection control consultant for IC Solutionsin Mount Pleasant, S.C. She can be reached by phone at (843) 849-6027, by fax at(843) 881-3714, or by email at firstname.lastname@example.org.