Winners in doubt
Hospital patients often contract infections before landing in a skilled nursing facility. But by understanding the difference between cleaning, sanitizing and disinfecting, providers can up their game
No respectable epidemiologist would like to admit it, but in the war against emerging pathogens and drug-resistant bugs, the germs are winning.
Germ warfare is constantly raging inside nursing homes, where environmental services and housekeepers are constantly fighting the good fight on multiple fronts.
From 2008 to 2012 alone, the number of citations under the F-Tag 4412 rule from the Centers for Medicare & Medicaid Services has doubled, underscoring what many have seen as big lapses in effective infection control practices inside nursing homes.
At least a small portion of the problems could be alleviated if skilled nursing staff had greater appreciation for the differences between cleaning, disinfection and sanitizing.
Given profound resource constriction and staff turnover, however, nursing homes are doing what many believe is yeoman's work staying in front of infections, as long as they follow best practices for cleaning, disinfection and sanitizing.
The top risks
According to the Centers for Disease Control and Prevention, up to 3 million people each year contract a serious infection inside a nursing home. As many as 200,000 of them wind up in the hospital and twice that overall die as a direct result of them.
No single infection has wreaked more misery than pneumonia — by far the leading cause of infectious disease-related death among nursing home residents, according to the Society for Healthcare Epidemiology of America and The Association for Professionals in Infection Control and Epidemiology, whose jointly produced, comprehensive “Guideline for Infection Prevention and Control in a Long-Term Care Facility” is among the leading resources today.
Other leading problems inside nursing homes include urinary tract infections, diarrheal diseases (major culprits include norovirus and Clostridium difficile), skin and soft tissue infections and antibiotic-resistant staph.
There are a host of reasons why nursing homes are a perfect storm for opportunistic infections. Yale University School of Medicine researchers most eloquently explain it this way in their recent journal article in Aging and Infectious Diseases: “Immunosenescence [the gradual deterioration of the immune system], multiple comorbid diseases, and grouped quarter living all coalesce in nursing home residents to increase the risk for infectious disease.”
According to Mike Weber, principal scientist, products research with Procter & Gamble Professional™, improper cleaning is a leading contributing factor to outbreaks of norovirus inside facilities. The nasty gastrointestinal bug easily and rapidly spreads from person to surface to person. It has become so ubiquitous in confined living environments that scientists have dubbed it the “cruise ship disease.”
On the other hand, over-prescribed antibiotics — and not necessarily poor cleaning methods — are the leading culprits in so-called “C. diff” infections, which often end in serious prolonged illness and death.
No quick fixes
Nursing homes often find themselves swimming against the tide when it comes to preventing and controlling infections. And no wonder. Among the biggest challenges have been decades of antimicrobial abuse, a dearth of industry-specific knowledge and the lack of a universal culture of safety.
It results in too many people finding themselves desperate for quick fixes. Ruth Carrico, Ph.D., nurse practitioner, FSHEA, CIC, associate professor in the University of Louisville's division of infectious diseases, believes too many are duping housekeepers.
“You can monitor for things like adenosine triphosphate [a marker for the presence of an active organism], but aside from that, there's really no way to know,” says Carrico. “We keep reaching for that magic bullet and forgetting about basic practice.” According to Weber, UV marker systems could be one way to check on the efficacy of cleaning and disinfection, but they are not widely used.
“The industry at large is having to address a very broad set of distinct yet interrelated populations. And if that weren't difficult enough, they're having to address some of the problems that we create in acute care,” Carrico adds. “In certain instances, we transfer patients from hospitals to a care environment that may not be either structurally equipped, economically equipped, perhaps even skill equipped, to address it.”
In part, the problem is exacerbated because the underlying processes allow it, according to Carrico.
“A worker may want to do something different, but if they've got to run down the hall back and forth all day, is that really going to be the priority?” she adds. “As anyone wearing a white shirt who has taken a full glass of red Kool-Aid and dumped it into the kitchen sink will tell you, it's highly likely you're going to splash some of it on you. You can't control physics.”
Another challenge comes from erroneous assumptions.
“Long-term care is in that situation where there's an overall lack of expertise in infection prevention and control, because everyone assumed the biggest risk was in acute care,” Carrico adds. “So now we have a bunch of folks saying you need to implement a lot of very costly interventions without having a defined plan and approach.”
According to the Advancing Excellence in Long Term Care Collaborative, best practices include appropriate use of personal protective equipment when cleaning and disinfecting, and handling soiled materials like linens; hand washing between resident encounters; closely following manufacturer directions when using chemicals; communicating to staff when a known infection is present; and setting routine cleaning and disinfection, as well as monitoring.
It also stresses the need for all skilled nursing staff to understand the difference between cleaning, disinfecting and sanitizing. Sadly, many still don't.
“While the descriptions of each process point out the differences, many staff often interchange the words, considering them to be the same,” says Chad Wyman, senior product manager, environmental, at Direct Supply. “It is important to know when to do one versus the other, or both.”
“Cleaning, disinfecting and sanitizing are all important components of fighting germs and combating the spread of infection, but they differ in their abilities as well as in their purposes,” adds Lori Strazdas, MPH, a scientist for Clorox Healthcare. “For infection prevention in long-term care facilities, it is important to select products that are specifically formulated and EPA-registered to kill the most prevalent and difficult to kill pathogens, such as norovirus and C. diff.”
Cleaning is intended to remove visible material and is an essential first line of defense, according to P&G's Mike Weber. But cleaning alone does practically nothing to kill many serious and deadly pathogens. EPA-registered disinfectants are required to be used to effectively do that job.
Even so, not all of such disinfectants are created equal. In many cases, the difference is in contact times or kill times. As a general rule, contact times are one to two minutes for bacteria, two to five minutes for viruses and 10 minutes for fungi and spores (such as C. diff). “There is a trend toward products with faster kill times, or less disinfectant contact time,” Weber adds. “Almost all products that deliver this are doing it at the sacrifice of cleaning capability, which means that a two-step process of cleaning and disinfection is essential.”
Low-level disinfection is always required on any devices or items that touch intact skin and high-level disinfection is called for with items that touch mouths, GI tracts or other mucous membranes, adds Timothy Bowers, corporate director, infection prevention and control for Inspira Health Network, and an APIC committee member.
Most agree that relatively new products like disposable cleaning and disinfecting wipes have advanced infection control practices in nursing homes. A 2015 study published in the American Journal of Infection Control concluded the wipes significantly reduced infections caused by C. diff, methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.
“A crucial differentiator between wipes and sprays is the fact that each wipe is pre-moistened with the recommended amount of germicide to achieve intermediate level disinfection, whereas diluted sprays can lose efficacy within hours,” says Joel Rich, director of Long Term Care and Alternate Care at PDI. “As a result, the continuity within the spray product cannot be ensured. Also, a pre-moistened wipe uniformly and consistently delivers the germicide to the surface, while sprays have no guarantee of uniform, consistent and complete application of the product.”
Experts agree, meanwhile, that consistent, comprehensive staff training and education is an essential element of effective infection control inside nursing homes.
Resources and training materials for caregivers are bountiful and most are easily found online with the CDC, CMS and organizations such as APIC, SHEA, the American Society for Healthcare Engineering and the Association for the Healthcare Environment.
An ideal resource is an infection preventionist, who can serve as an important resource for providing tools, training, education and audits to monitor and maintain a safe and sanitary environment for the residents and staff, according to Patricia Howell, RN, a member of McKesson's Clinical Resource Team.
Such an individual can also provide competency testing, coordinate annual training and “provide opportunities for improvement by including staff at levels when working performance improvement plans.”
According to Wyman, any good plan should: ensure the staff understands the importance of regular cleaning and disinfection; provide formal, regular training; require staff to know the products; allow the proper amount of time to perform tasks; implement a quality control system; and reward good work regularly.
Carrico admits the job of infection control in long-term care continues to challenge even the best and brightest.
“We've got to be not only smart about our actions but smart about our resources consumption,” she says. “In order to control that, we've got to have a plan in place.”
In the end, a plan that sticks to well-established and acknowledged best practices is the best course.
“Our proven basics are focusing on hand hygiene and fundamental environmental infection control,” Carrico says. “That means regular cleaning and disinfection, and empowering staff. You can't just dabble in infection control. It's one of those things where you are either all in or all out.”