Seasonal shifts

Sterilization is as important as hand washing when preventing flu infection. Many infections are spread through touch.
Sterilization is as important as hand washing when preventing flu infection. Many infections are spread through touch.

It's that time of year: The vaccines have been distributed, the cases are mounting and long-term care facilities are on high alert for cases of the flu.

Some 200,000 Americans will be hospitalized with the flu or complications this season, says the Centers for Disease Control and Prevention. Those patients won't be alone in the emergency room: Cold weather also drives up cases of Respiratory Syncytial Virus (RSV) and, according to new research, leads to more Clostridium difficile infections come early spring.

But just because people tend to get sicker at certain times of year doesn't mean they have to.

Well thought-out strategies that combine best practices with modern products and equipment can help nursing homes protect their residents even in the midst of a community or regional outbreak.

“Within long-term care facilities … residents and clinicians are constantly within close quarters of one another,” explains Martie L. Moore, chief nursing officer for Medline Industries. “When you couple that with the right temperatures for viruses to hang in the air longer, there is a heightened risk.”

Because it is both widespread and especially dangerous for seniors, flu gets much of the attention. Some of the precautions meant to stop its spread can work against other viruses, but for threats like C. diff, additional strategies are a must.

No matter what bug or virus they'll be battling, administrators must plan ahead, increase prevention activities (and maybe spending) as they head into peak season, and stock up on supplies, experts say.

Spreading the word about techniques that work and getting employees to buy in will also translate to better outcomes, says Mary Madison, RN, clinical consultant for Briggs Healthcare's long-term care and senior care assisted living clients.

“When you're charged with taking care of people, if you're in the healthcare industry, then you have a responsibility to do everything you can to protect your patients, yourself and your own family and friends,” she says.

Knowing when it will hit

Although medicine can help flu sufferers, not all prescriptions are helpful.

A study published in May in the American Journal of Infection Control found that C. diff cases spike in March, representing an established lag time between antibiotic exposure and development of the infection. (The study also found that C. diff mortality was highest in winter.)

Previous research has found increased C. diff incidence after seasonal spikes in flu, pneumonia and RSV. That makes early winter prime time to implement stewardship programs and work with caregivers, family and residents to decrease reliance on antibiotics.

David A. Nace, M.D., MPH, of the University of Pittsburgh School of Medicine is heading a $1.5 million national trial to examine methods that can reduce antibiotic use in post-acute and long-term care. It will focus on managing urinary tract infections, commonly misdiagnosed and incorrectly treated — often with repeated courses of antibiotics.

“All it takes is one exposure to antibiotics in people 65 and over,” says Nace, chair of AMDA's infections advisory committee. “You really have to make sure your choices make sense.”

Facilities should track which antibiotics tend to fail in their settings and share that information with doctors. Physicians, in turn, should only use antibiotics when they have ruled out a virus and then prescribe a narrow-spectrum drug.

In September, the CDC released “Core Elements of Antibiotic Stewardship for Nursing Homes.” The guide recommends using literature, face-to-face workshops and electronic communication to educate staff about the dangers of antibiotic use.

Nace says it can be helpful to share with doctors when several residents have similar symptoms. If so, they almost certainly have a virus that won't respond to antibiotics.

Nurses also need to play a role in offering recommendations or observations to an on-call physician, says Patricia Howell, RN, clinical support manager for McKesson Medical-Surgical. 

“If they do, doctors are less likely to send the resident to the ER or throw an antibiotic at them,” she says.

The CDC guide also acknowledges that winning families over can be a help in decreasing nursing home antibiotic use.

“You have to stick to your guns and be confident,” says Howell. “Arm yourself with all the necessary weapons.”

She's a fan of “Living with C. diff,” a pocket guide published by the Arizona Healthcare Associated Infections Program. It clearly links antibiotic use to C. diff, and illustrates just how dangerous an infection can be to vulnerable residents.

Consistent caution

The same basic problems that embolden the flu — communal contact, shared air circulation and equipment, post-acute arrivals — also put residents at risk for C. diff.

Beverly Spencer, business team leader for healthcare training for Clorox Healthcare, talked prevention during a McKnight's webinar in June.

Spencer says 80% of infections are transmitted by direct or indirect touch, making sterilization just as important as hand washing.

Pat Vanderheiden, vice president of Vancare, says sales of his company's ESS Cart tend to peak in winter months when operators are more likely to invest in infection control. The mobile electrostatic disinfecting system works by spraying charged droplets that coat and disinfect all sides of an object, from a bedside table to a remote control. Two different cleaning solutions make it a viable option to prevent spread of flu and C. diff.

Whether cleaning by hand with bleach mops and wipes or using a newer spray solution, disinfecting is not a once-and-done chore. C. diff patients should be isolated in special rooms and quarantined whenever possible.

As Nace notes, settings with ambulatory yet cognitively impaired residents may find restricting movement especially hard. Staff should know who is infected and always wear protective gowns and gloves when working with them, their belongings or anything they might have touched. 

C. diff itself is extremely difficult to kill. Spores can live for six months, and Nace says new research shows even the best methods leave C. diff on endoscopes. More specialized products are coming to market designed to disinfect specific equipment, including the Cleanint system intended to kill germs on stethoscopes.

Even the best precautions can be undermined if caregivers take shortcuts, sometimes leading to penalties.

When one of Madison's clients failed to sanitize a Hoyer lift with bleach between patients during a site visit, for example, the facility was hit with an Immediate Jeopardy violation.

Danger is always around the corner. Moore recently watched a caregiver go from room to room without changing gloves between patients. Such overconfidence is “misguided and contributes to why we continue to fight infectious disease,” she says.