Catching bad bugs
41% of multi-drug resistant infections are acquired when nursing home residents are hospitalized, mo
An invasion of new “tough bugs,” combined with an expanding post-acute care environment, has put heavier emphasis on the infection control fight as the stakes in protecting residents grow higher. With the populations of long-term care facilities steadily climbing and increasingly vulnerable to infections, it is a mounting challenge that requires more attention and commitment, infection control specialists say.
“Today's regulatory arena is placing post-acute care facilities under intense scrutiny with regard to infection prevention activities,” says Lorri Downs, RN, vice president of clinical services, infection prevention and patient safety for Medline Industries. “In part, this is because healthcare-associated infections generate significant press and shift the focus from the national stage to the local community.”
Downs says the infection risk is ballooning, with approximately 1.5 million adults living in long-term care communities; an estimated 756,000 to 2.8 million infections are occurring in these facilities annually. Moreover, conservative estimates of the financial costs associated with morbidity and mortality suggest this population accounts for approximately 150,000 hospitalizations each year with a $673 million price tag, along with 380,000 deaths annually.
With the expansion of the post-acute care environment, the infection threat has spread into smaller settings as well, says Tom Bergin, marketing director for SCA AfH Professional Hygiene.
“With healthcare reform there is a growing linkage among all healthcare practitioners, including doctor's offices, LTC facilities and hospitals,” he says. “We are hearing about a lot of hospital readmissions after people return to an LTC facility or visit their doctors. Many times that is due to infections that could be contracted in any of those three places.”
Consequently, infection prevention and control “is one of the hottest topics for both accreditation and regulatory surveyors due to the significant risk for infected residents,” says J. Hudson Garrett Jr., Ph.D., senior director of clinical affairs for PDI. The Centers for Medicare & Medicaid Services and the U.S. Centers for Disease Control and Prevention have made the prevention of healthcare-associated infections a top priority in both evidence-based guidelines and standards, but also in the accreditation and regulatory aspects of the CMS survey process, he says.
“Surveyors are consistently requiring substantial demonstration of a comprehensive infection prevention program,” Garrett says. “This program must focus on healthcare provider participation as well as resident involvement in the facility's infection prevention and control.”
The communal living conditions of long-term care residents raise the risk for transmission and acquisition of a healthcare-associated infection, Garrett says. Moreover, he says the microorganisms themselves continue to mutate and adapt to the environment, and are “in many cases beating out antibiotics.”
Carbapenem-resistant Enterobacteriaceae (CRE) is the latest example of an infection that can be difficult — if not impossible — to kill, joining Methicillin-resistant Staphylococcus Aureus (MRSA) as a troublesome foe for infection control professionals. Clostridium difficile and norovirus are also stubborn pathogens that infection control professionals have battled for years.
“C. diff today gets the highest level of focus due to the resilience of its spores,” says Dustin Teske, environmental equipment consultant for Direct Supply. “While in a vegetative state, C. diff is easier to kill because it can only live for a few hours due to an inability to tolerate oxygen. But when it is in a spore state, it can live up to five months, re-introducing itself to the environment at any time and exposing the facility to new risk.”
Bleach is the most common C. diff disinfectant when properly diluted, but the Environmental Protection Agency also has added other hydrogen peroxide products and a silver-based product to its approved list, Teske says.
CRE is not as common, but it has become a lethal threat due to its resistance to nearly all antibiotics available today. The CDC reports that the infection causes death in up to half of the patients who contract it and that the infection rate is on the rise, with 18% of long-term acute care facilities experiencing a case in 2012.
Other serious threats, Downs says, are Pseudomonas aeruginosa, a bacterium found in soil and water that is “intrinsically resistant to many antimicrobials,” and Extended Spectrum Beta-Lactamases (ESBL), which are antibiotic-resistant bacilli.
If there is a silver lining, it is that most of the emerging threats exist primarily outside facilities and that they do not require any new cleaning or disinfection procedures, Garrett says.
“The most recent example would be the CRE class of microorganisms, which is resistant to most antibiotics, but transmission can be mitigated through environmental cleaning, hand hygiene and judicious use of antibiotic agents,” he says.
The lurking presence of virulent pathogens has CMS and accreditation surveyors focusing on F-Tag 441, which deals directly with infection control and prevention. Citations center on deficiencies in hand hygiene, sharps safety, and cleaning and disinfection of medical equipment.
Several states are also asking about disinfectants' “kill times” and “dwell times,” Teske says. The kill time is the length of time required by the EPA for a disinfectant to kill, as opposed to dwell time, which is a period in which the disinfectant chemical is wet and effective on a surface.
“Your kill time must be shorter than dwell time for a single application to work,” he says.
Surveyors are also looking for details on outbreak management processes, Teske says.
“I have learned about surveyors shadowing a housekeeper and specifically watching to see that the high-touch areas are addressed, that chemicals are being used for kill time and dwell time requirements and that protective equipment is worn,” he says.
Improper use of sharps, along with failure to properly clean and disinfect glucometers, are at the top of the CMS most-cited list, Garrett says. The seriousness of the violations, he says, relates to documented outbreaks and transmission of bloodborne pathogens, including HIV and Hepatitis B, in both situations. These are preventable “but require facility and unit-based accountability to follow the proper policies and procedures, as well as evidence-based clinical guidelines for disinfection from the CDC,” Garrett says.
Proper hand hygiene may seem like the most elementary part of infection control, but the reason why it is at the top of surveyors' citation list is that protocols aren't followed often enough, infection control specialists say.
“Any strong infection control program should include a hand-hygiene program — not only for staff, but for residents and their visitors as well,” Bergin says. “While staff members are usually educated and have the materials needed to properly wash their hands, there is a risk of infection spreading with residents and their families. Touchless sinks, soap dispensers and paper towel dispensers are a great solution to reduce the spread of infections.”
A comprehensive prevention program emphasizing hand hygiene and environmental cleaning, for example, helped a Pennsylvania high-acuity long-term care facility keep the H1N1 virus largely away, Garrett says.
The program centered on hand washing for residents, staff and visitors and focused on environmental cleaning and disinfection of shared medical equipment and high-touch surfaces.
The results: The facility had reductions in the incidence of healthcare-associated infections, a reduction in the use of antibiotics and staff absenteeism, plus zero cancellations of resident activities as a result of influenza activity, Garrett says.
Teske adds that use of microfiber mops and surface cleaning towels more than doubles the infection control effectiveness of traditional cotton products (99% versus 44%). By improving inner air quality, he says, air purification systems also contribute to the overall atmosphere and cleanliness of a facility.
Infection prevention must be “everyone's business,” Downs emphasizes.
“As increased monitoring of hand hygiene, gown and glove adherence cleaning, and disinfection practices are reviewed, it will be key during a survey that staff members can articulate how they are protecting residents, especially from acquisition of healthcare-associated infections,” she says.