A war on bugs

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AHRQ gives $34 million to nursing homes, other settings to fight healthcare-associated infections
AHRQ gives $34 million to nursing homes, other settings to fight healthcare-associated infections
As newer and stronger pathogens develop in healthcare environments, long-term care experts are struggling to stay ahead of the bacterial curve. 

It isn't easy, but nobody plans on giving up without a fight. Providers are reaching deeper into research and government support.

Meanwhile, manufacturers have bolstered efforts to combat this new generation of germs.

“As infection outbreaks have grown, efforts have been made to re-emphasize and ‘beef up' infection control protocol,” said Lin Cochran, vice president of operations for AirScrub Systems at Clean Air Systems Engineering in Aiken, SC.

“Unfortunately, outbreaks are still a threat. This is primarily due to infectious contaminants brought into a facility by visitors, staff and delivery personnel. Noroviruses, for example, are extremely contagious and very fast-spreading. This virus is acquired by contact with a person carrying the virus or by touching something the carrier has touched,” Cochran explained.

“No amount of protocol can prevent the spread of this virus unless someone goes behind each person and sanitizes every surface the carrier has touched, including doorknobs, handrails and furniture.”

There are myriad products available to help long-term care staff keep a lid on health-threatening pathogens that invisibly lurk around facilities. But the best weapon in the fight against infections continues to be hand hygiene.

Regular hand washing – and that goes for residents and visitors, as well as workers – remains the first line of defense in protecting the population's health, infection control specialists say.

“The Centers for Disease Control and Prevention and other health organizations recognize hand hygiene as one of the best methods for reducing the spread of infections,” said Dave Mackay, vice president of healthcare marketing for Akron, OH-based GOJO Industries.

“Staff, resident and patient health is dependent upon hand hygiene compliance. Non-compliance places staff and residents at risk – it can ultimately lead to higher healthcare costs and could result in litigation.”

On the surface, hand washing seems like a rudimentary – almost innocuous – practice when compared to the complex nature of fortified germ breeds. Yet, as improbable as it might seem, cleansing with soap and water is nonetheless highly effective in stopping contagions cold. 

“Regarding the spread of disease, we're talking about a multi-stage cycle – there is the microorganism itself, the mode of transmission, entry into a susceptible person and subsequent growth. Hand washing will cut off the infection at any point within that cycle,” noted Susan Duda-Gardiner, director of clinical services for the Illinois Council on Long-Term Care, on why hand hygiene is so integral to infection control.

Although soap and water cleansing may be the best method of hand washing, in reality, it can be difficult for busy workers to find a sink after every encounter. That is why hand sanitizers have become a popular and effective substitute, Duda-Gardiner said.

“Hand sanitizers are actually fairly new to the long-term care industry and they are phenomenal,” she said. “While soap and water is preferred – especially for C. diff — the sanitizers are great because of their portability and convenience. You can carry a bottle around in your pocket so that you can use it after every resident contact.”

Major cause of death 

The CDC estimates that healthcare-associated infections are among the top 10 causes of death in the United States. Major regulatory and professional organizations, such as the CDC, Association for Professionals in Infection Control and Epidemiology (APIC) and the Joint Commission (formerly JCAHO) regularly issue bulletins to clinical personnel about the evolution and mutations of virulent, antibiotic-resistant bacteria, known as “superbugs.” 

They include methicillin/oxacillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum beta-lactamases (ESBLs) and penicillin-resistant Streptococcus pneumoniae (PRSP). These are in addition to the usual list of biological interlopers, such as HIV, tuberculosis, Clostridium difficile, Hepatitis C, scabies, influenza and norovirus.

To stave off the persistence of constantly mutating diseases, long-term care administrators can rely on Section F441 of the Omnibus Budget Reconciliation Act of 1987, and CDC infection control guidelines for direction. Following the requirements set forth in OBRA and the Atlanta-based disease management agency, facilities have the basic fundamentals for investigating, controlling and preventing infections.

Infection origins

Nowhere is the challenge of fighting nosocomial infection greater than in one of the most likely pathways to a long-term care facility: the acute care sector, where MRSA and VRE are becoming more prevalent, Cochran said.

“It seems that it has gotten to a point where almost everyone knows someone who became infected during a hospital stay,” she said. “The sad part is that MRSA, once primarily a ‘hospital acquired' infection, today also is ‘community-associated,' meaning it is spreading into non-hospital situations, such as schools.”

To help prevent the introduction of community-based microorganisms into the long-term care resident population, many facilities are now setting up information kiosks that instruct visitors on proper infection control protocols. Postings may show visitors proper cough etiquette and other disease prevention techniques. Some may even advise those with colds to refrain from visiting, Duda-Gardiner said.

Prevention attention

Because MRSA and potentially other pathogens such as C. diff have spread beyond institutional walls and into the community, infection control professionals are on heightened alert to safeguard the vulnerable elderly and infirm populations.

“When it comes to the next pandemic, it is no longer a question of ‘if,' but ‘when,'” Duda-Gardiner said.

Could that pandemic be C. diff? The threat is real enough that APIC has launched a survey of infection control practitioners to determine its pervasiveness. The CDC reports that the number of states confirming the NAP1 C. diff strain jumped from 23 in February 2007 to 38 in November. While C. diff has been a longtime fixture on the long-term care scene, infection control professionals are concerned that its scope has spread and its toxicity is strengthening.

“The true magnitude of [C. diff] is still unknown,” APIC notes on its Web site. “Over the past 30 years, this pathogen has rapidly emerged as an important healthcare-associated infection, causing a spectrum of diseases, including diarrhea, colitis, toxic megacolon, sepsis and death. Other than the CDC's National Nosocomial Infections Surveillance data taken from approximately 250 hospital ICUs and patient discharge records, there are no national C. diff prevalence studies.”

Results of the study will be released at a special APIC conference in November.

The technology front

Misuse of antibiotics is the main reason mutant superbugs have evolved and thrived, infection control professionals say. Between the over-prescribing of antibiotics by healthcare professionals to improper drug adherence by patients, various staph strains have acquired immunity. 

It is a mistake that many in the healthcare industry have vowed not to repeat. Pharmaceutical manufacturers reportedly are working on developing new versions of antibiotics to combat MRSA and other virulent bacteria. But no timetable for their introduction has been indicated at this point.
Sophisticated technology, such as the AirScrub System, is a radical departure from traditional infection control methods. Working in tandem with the existing air handling system, it propels what company officials call “super oxidizers” into the facility. These oxidizers are designed to scrub both air and surfaces continuously so that contaminants brought in by visitors are immediately killed.

Still, Cochran admits that the system might be a bit ahead of its time at this point.

“It is hard for administrators to relate to this technology due to the fact that infection control has always had a set of procedures that must be followed and they tend not to look beyond that for prevention,” she said. “Obviously, we encourage our clients to continue the infection control protocol, such as hand washing, gowning, isolation and proper disposal of contaminated items, but we also are hoping to provide them with  higher levels of security and safety for their residents and staff.”
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