Care for the caregiver
As infection control mandate advances, nurses need to focus on themselves
There's an old saying about the road to hell being paved with good intentions.
During her 20-year career as a nursing home administrator, Janine Finck-Boyle witnessed her share of residents suffering with various infections, some of which probably found an open door by way of a caregiver's soiled hands or clothing.
Even today in her role as LeadingAge's director of health regulations and policy, Finck-Boyle, MBA/HCA, LNHA, shakes her head whenever she sees a young nurse on her way to work in the scrubs she'll likely wear over the next eight hours.
Caregivers' passion and concern for residents are largely above reproach, but in their haste to pass meds, perform rounds and all the other “stuff” in the average workday, many nursing home staff often overlook taking care of themselves, and in the process, become unwitting conduits for opportunistic infections.
Complacency is a culprit, as identified by a 2015 study that found alarmingly low flu vaccination rates among nursing home staff, despite influenza claiming the lives of more than 7,000 skilled nursing facility residents per year. That study was published in the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology.
Admittedly, positive movement on issues like these could be hard to come by.
Even when they witness risky staff behavior like hand washing neglect, many residents are unwilling to voice their concerns, noted Gina Pugliese, RN, MS, FSHEA, vice president emeritus of the Premier Safety Institute®.
One solution involves appealing to caregivers' instincts for self-preservation.
“In my opinion, few caregivers stop to think about the impact their lack of hand hygiene compliance can have, unless they or a loved one experience a nosocomial infection, because they do not see the consequences of their actions,” observes Elaine McGowan, BSN, RN, CWCN, vice president of clinical affairs for Dermarite.
Whatever path is chosen, skilled nursing providers are now facing unprecedented scrutiny from federal regulators for implementing infection control programs, and the penalties can be severe.
According to the Centers for Disease Control and Prevention, as many as 3 million serious infections happen every year inside nursing homes, claiming the lives of nearly 400,000 people along the way.
Many experts easily acknowledge that poor personal hygiene among staff is a major weak spot. As Therese Laub, LPN, CWS, a wound care/product specialist at Gentell, told
McKnight's, it has been suggested that 62% of men and 40% of women do not wash their hands after using the toilet. “This is a problem,” she says tersely.
Another weak spot is poor training, according to Deb Patterson Burdsall, Ph.D., RN-BC, CIC, FAPIC, who serves as faculty for APIC's “EPI® 101 for Long-Term Care” course and is an editor for APIC's forthcoming Infection Prevention in Long-term Care manual.
“Infection prevention is a specialty, like wound care and MDS coordinating,” she says. “Specialized training is required. Too many times, infection prevention has been an add-on position. It needs to be seen as a specialty in its own right.”
There are numerous sub-specialites within an infection control specialist's purview. Some that are often overlooked involve nurses' own hygiene and care.
Chris Tiemann, national sales director post-acute care for Theraworx, is a strong advocate for skin care, which he believes is a woefully overlooked area of personal hygiene in many healthcare workers today.
“The biggest weak spot is continuing to utilize products and protocols that can degrade the skin and lead to more vulnerabilities for infection,” Tiemann says.
He adds that while harsh soaps, alcohol, and chemicals such as chlorhexidine gluconate [CHG] are highly effective infection control agents, they wreak havoc on and compromise the integrity of skin by disrupting the organ's layer of healthy bacteria, or microbiome, and creating opportunities for infection.
Tiemann urges any workers exposed to the cleaning agents to use products that create a low pH environment, in order to support the microbiome and optimize skin's natural antimicrobial and barrier properties. Such products have shown to be the best defense against infection.
“This is new science to prevent infection, and steers us away from typical products that have been utilized in healthcare for the past 50 years,” Tiemann asserts.
‘Mega' challenges ahead
Nursing homes' new requirements of participation put infection control front and center.
Facilities must now establish and maintain an infection prevention and control program for identifying, investigating, reporting, preventing and controlling infections and communicable diseases for residents, families, the public, and staff.
That mandate, in tandem with another that requires all facilities to have an antibiotic stewardship program in place, leave no doubt how serious federal regulators are about curbing acquired infections and rehospitalizations.
“[Nursing] facilities will need to ensure they have systems and procedures in place for surveillance and early detection, and demonstrate how they're managing potential infections,” says Finck-Boyle.
The biggest hurdle is yet to come in November 2019, when all facilities will need to have designated one or more individuals as infection preventionists. This is a highly specialized role few nursing facilities currently fill.
The qualifications “are a little open-ended,” so far, Finck-Boyle notes. “That person's sole job is to do infection prevention and control immunizations — the whole program.”
For now, many facilities are having to relearn the entire survey landscape when it comes to infection prevention.
“CMS has overhauled and re-numbered the F-Tags and made everything really resident-centered,” Finck-Boyle adds. “Not only did they re-tag everything, but they created all new interpretive guidance, all focused on the requirements of participation in the mega-rule.”
Finck-Boyle cautions facilities to pay close attention to the mega-rule's immunization requirements.
“You cannot forget immunizations because [providers] will need to ensure it's facility-wide,” she says. “Even though up to now, a facility with a baseline infection prevention and control program would receive an infection control deficiency if a staff member was caught handing out snacks to residents with ungloved hands or not changing gloves from a prior activity, the new rules are far more proactive in scope.
“Although everything is going to be resident-centered, this particular prevention and control program is also looking at the staff,” Finck-Boyle adds. “That means making sure they're wearing gloves and other appropriate personal protective equipment. While they are obviously there to protect the frail and compromised individuals in your facilities, staff will need to make sure they have other pieces of the puzzle.”
Given current events and the future mandates, there's never been a better time for nursing homes to review best practices for staff infection control.
Experts point to F880. This F-Tag covers the gamut of infection control and process surveillance, from hand hygiene, appropriate use of personal protection equipment, injection safety, point-of-care testing, and infection control practices to managing bloodborne pathogen exposure, cleaning and disinfection products and procedures, appropriate use of transmission-based precautions, and handling and transporting linens.
Todd King, Omnicare director of clinical services, explored F880 in depth during an October
McKnight's webinar on the mega-rule. Among activities surveyors will be looking at are “observation of staff who fail to use effective practices, such as poor hand hygiene or failure to use the appropriate protective equipment, and also any unusual or unexpected outcomes that are identified such as a foodborne outbreak,” King says. “Once all of this data is collected and analyzed, it is essential that a facility knows how it will provide this data in reports to staff and/or prescribers so that education and interventions or approaches can be revised to improve the overall infection prevention and control program.”
Here's a look at some of the key best practices for nursing home staff.
Hand hygiene. No doubt the biggest yet often ignored best practice, hand hygiene practices of staff are going under the microscope. Lisa Logan, R.D.,CNSC, enteral program manager/nutrition support clinician for McKesson Medical, suggests cameras or electronic surveillance to monitor handwashing before and after resident contact.
“Driving compliance to 100% is an ongoing challenge. Why? There are plenty of reasons and excuses, including the classic ‘too busy' and ‘supplies/equipment not readily available at point of care,'” adds McGowan.
The current CDC guidance describes hand hygiene as cleaning hands by using either handwashing [with soap and water], antiseptic hand wash, antiseptic hand rub [i.e. alcohol-based hand sanitizer including foam or gel], or surgical hand antisepsis. The CDC also states alcohol-based hand sanitizers are “preferred” when hands are not “visibly soiled.”
Handwashing must be performed: before eating; before and after having direct contact with a patient's intact skin; after contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; if hands will be moving from a contaminated-body site to a clean-body site during patient care; after glove removal; and after using a restroom.
One of the most overlooked opportunistic practices comes in passing medications, according to Finck-Boyle.
“Residents on average are on nine medications, so the licensed nurses are giving meds on their med carts the majority of their shift,” she says. “That is a prime area where you need to be washing your hands.”
Tiemann urges caregiving staff to use acidic soaps when hand washing to maintain the skin's natural antimicrobial properties. Despite current rules, he says he doesn't believe alcohol rubs are “a good alternative to soap … and may be doing more harm than good.”
Personal hygiene. Some providers may be puzzled having to lecture their employees about personal hygiene, but regulators now have evidence to show it is a problem, and a huge open door to infection spread.
“Personal hygiene and cleaning of surfaces are critical steps in every senior living home, and education and consistent reinforcement should be provided to ensure they are routinely done,” says Karen Stash, chief marketing officer for Novaerus.
Stash believes the infection preventionist provision in 2019 will bring the matter of personal hygiene to the forefront.
Finck-Boyle thinks more nursing facilities would do well to provide personal space (including lockers) for staff to change from street clothes and freshen up before reporting to the floors.
“Nursing homes all over have different incentive-type programs to achieve lower infection rates and ensure they're meeting quality measures,” she says. “But they also need to think about additional ways they can strategically work with the staff on these kinds of issues.”
Housekeeping and environmental services. In many ways, they are the gatekeepers. Tiemann says their importance in keeping the environment clean isn't the only role they play in infection control.
“They can be the champion for infection control in the building and be a positive influence on other staff,” he adds.
Another overlooked area inside facilities is the air itself. Stash believes unlike hand washing and surface disinfection, air purification is not well understood and yet is a core part of facility management.
Training and education. There never seems to be too much of it, and new pressures will demand more of it.
“Education, to me, is the most vital aspect of gaining acceptance of good personal hygiene,” reminds Tiemann. “Educating staff to understand that these measures are in place to help protect them as well as the residents and how they work is vital to gain buy-in.”