Infection Control Feature — Under attack

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With contagions becoming more prevalent in facilities, a strong prevention program can be the best defense.

Martha Harris will not likely forget Christmas last year. While many people were unwrapping gifts and gathering with loved ones, Harris was working to contain the spread of the Norovirus. It had hit the Cameron Glen Care Center, a nursing home located in Reston, VA.
"A few of us were there from 6 a.m. to 8 p.m., ushering people back and forth so they could see [residents]," Harris recalls.
Thankfully, because of employees' understanding of proper protocols and procedures the outbreak did not last more than two days after the holiday.
"We effectively shut down the progression of the virus," said Harris, the infection control practitioner for Inova Health System, a not-for-profit healthcare provider based in northern Virginia.
Not all nursing homes are so fortunate. Infectious outbreaks – which include everything from seasonal flu to Norwalk virus – attack nursing homes on a regular basis, sometimes with devastating consequences. Consider a recent food poisoning outbreak in a facility in Australia: It killed four and led to the ouster of the chief health officer in Victoria.
As awareness about healthcare-associated infections grows, experts stress the importance of adhering to infection control guidelines and procedures. And addressing proper cleaning protocols could go a long way in preventing and containing the spread of harmful microorganisms.

Spreading out
Outbreaks have been attracting a lot of attention these days.
Healthcare-associated infections are the "topic du jour," said Aaron Calloway of Kimberly-Clark Professional, which produces the WetTask Wiping System, an enclosed cleaning system.
HAIs, or nosocomial infections, include everything from respiratory infections to the methicillin-resistant Staphyloccus aureus (MRSA), which is growing at an alarming rate.
HAIs are estimated to occur in 5% of all acute care hospitalizations, according to Dr. Quoc V. Nguyen of the New York State Health Department. The estimated incidence is more than 2 million cases per year, resulting in an added expenditure in excess of $4.5 billion.
Hospitals are not the only offenders. A study published in April found that patients admitted to The Johns Hopkins Hospital who resided in long-term care facilities over the last six months were far more likely than other adult patients to carry, or be infected with the drug-resistant super bug MRSA.

Small battles
Although tough, killing these hearty germs is not impossible. It involves a multi-pronged approach consisting of education, strict adherence to infection control practices and proper cleaning procedures, experts say.
When infection control practitioner Harris heard about Norovirus, a group of viruses that causes acute gastroenteritis, in the larger Reston community, she immediately took action, warning staff and preparing them for a possible outbreak.
"People were prepared, knowing what to do so they had tools of good infection control right at their hands," Harris says.
She stresses the importance of education and following established guidelines from the Association for Professionals in Infection Control and Epidemiology and the Centers for Disease Control and Prevention.
"The quicker we can identify a trend, the sooner we can put in the right infection control procedures and stop it from spreading throughout the facility," she says.
The first sign of Norovirus sent her staff to work, bleaching the floors of the infected rooms, and employing hand hygiene and contact isolation with the infected residents. Also, in step with her company's policy, she notified the public, telling them either to reschedule visits or to follow guidelines for coming into the facility.
She beams about her staff and the Inova administration, who, she believes, worked admirably during a difficult time.
"With the Norovirus outbreak, it was the 'power of one,'" she said. "Everyone had to follow the guidelines at the time to shut this down. It wasn't one person ... It was the staff working together. If they hadn't all worked together, we wouldn't have got it done."
As a microbiologist by training, she grasps the strength of dangerous bacteria: "It's a respected enemy. You need to know about the bacteria to know how to deal with it."
Missed opportunities
Properly cleaning the facility plays a role in containing and preventing outbreaks.
Most facilities don't clean thoroughly enough, argues Chris Wilkerson, president of EquipSystems, an equipment cleaning company for healthcare facilities.
"Equipment is not being cleaned or disinfected," he said. "They are a nidus (breeding place) of infection."
While they may scrub the floors, staff often neglect to clean equipment such as wheelchairs, overbed tables, blood pressure and vital stands, and gerichairs, he said. Those areas are usually rife with bacteria.
"Many people carry MRSA in their nose so you have a population shedding skin cells, sitting in their chairs, maybe incontinent," he said. "You've got a whole bunch of bodily fluids being passed across people and equipment."
It's those places that you don't see, such as below the cushion of a gerichair, that could be the prime areas of bacterial growth, he said. The company recently conducted a study in a hospital to determine the amount of bacteria, viruses and fungi on non-critical equipment surfaces both and after cleaning. Items included stretchers, gerichairs and overbed tables.
"Our results showed that even the most dangerous bacteria were present in alarming quantities on all surfaces tested," he said.

Product knowledge
Knowing which products to buy can make a difference in stopping the transmission of bacteria, he and other experts acknowledge.
Read the label, advises Kelly Ticco, marketing manager for SafeTec of America, which offers products such as antimicrobial hand cleaners and hand wipes. Labels tell which microbes the product has been tested to kill.
"If you are not seeing it on there, call the manufacturer to make sure what you are using to clean the facility is killing what you need it to kill," she said.
Labels also provide important guidance as to mixing rules and contact time – how long a product should be left on a surface before it is wiped or scrubbed away.
Before purchasing a disinfectant, make sure it is registered with the Environmental Protection Agency, Ticco says. The agency has to approve all surface disinfectants, which are considered antimicrobial pesticides.
Joan Holtschlag, a research and development chemist for Caltech Industries Inc. recommends disinfectants over sanitizers for healthcare facilities. The difference? Sanitizers kill 99.9% of offending organisms, while disinfectants eradicate 99.99% of nasty germs.
While that might not seem like a big difference, "it's an order of 10 so it's a lot more," she says.
Some common active ingredients in disinfectants include: quaternary ammonium compounds, O-Phenylphenol and sodium hypochlorite, otherwise known as bleach.
She notes that this good old-fashioned whitening agent may be the best defense against the spore form of dangerous bacteria, such as C. diff. While many products have claims for killing the vegetative form of bacteria, no product yet has an EPA claim for killing the more insidious spore form, she said.
The CDC currently only recommends using bleach to kill the spore form, Holtschlag said.
She offers one note of encouragement in the battle against vicious germs: While microorganisms such as MRSA are resistant to some antibiotics, they are not becoming resistant to disinfectants.
"The cleaning should be done diligently," she said. "If you have a well-educated cleaning staff, I think you can cut down on the outbreaks before they even start."

Facing facts: Healthcare-associated infections (HAIs)
- HAIs infect 2 million people annually in U.S. hospitals.
- HAIs cost between $5 billion to $6 billion annually and result in almost 100,000 deaths in the U.S.
- U.S. hospital Clostridium difficile associated disease discharges doubled from 1996 to 2003.
- In 1974, only 2% of staph infections were MRSA (methicillin-resistant Staphylococcus aureus). By 2003, that figure had soared to 57%, and now is over 60%.
- An estimated 70% of the bacteria that cause infections for 2 million hospitalized Americans each year are resistant to at least one of the drugs most commonly used to treat them.
Sources: Centers for Disease Control and Prevention; Association for Professionals in Infection Control and Epidemiology; Joint Commission on Accreditation of Healthcare Organizations; Managing Infection Control, October 2006

Fighting the flu
Some measures to prevent flu transmission and to control flu outbreaks in long-term care facilities:
1. Surveillance – Use testing to identify outbreaks early.
2. Education – Teach personnel about signs and symptoms of flu and control measures.
3. Influenza testing – Develop a plan for performing rapid flu testing.
4. Respiratory hygiene/ cough etiquette program – Provide tissues or masks to residents and visitors who are coughing or sneezing.
5. Standard precautions – Wear gloves during hand contact with potentially contaminated surfaces.
6. Droplet precautions – Place the resident who has suspected or confirmed influenza in a private room for five days after the onset of the illness.
7. Restrictions for ill visitors – When flu occurs in the surrounding community, notify visitors that adults with respiratory symptoms should not visit for five days.
8. Antiviral Chemoprophylaxis – Administer the medication to residents and healthcare personnel during outbreaks.
9. Other considerations – Allow residents with symptoms of infection to participate in activities – at a three-foot distance from other residents.

Source: Centers for Disease Control and Prevention, "Infection Control Measures for Preventing and Controlling Influenza Transmission in Long-Term Care Facilities," Feb. 6, 2007