Germs put on notice
Germs put on notice
Germs are like biological terrorism — an invisible enemy whose presence isn't known until it strikes. Unfortunately, by then serious damage might have been inflicted.
That is a difficult scenario to guard against, to say the least. Yet that is the infection control challenge that long-term care facilities face every day, and it is a vigil that disease specialists say is more critical to uphold than ever.
“With the elderly population being more susceptible to infection and serious complications, the need to address these issues has become vital for long-term care and assisted living facility managers,” says Allison Aiello, Ph.D., associate professor of epidemiology for the University of Michigan School of Public Health and member of the Tork Green Hygiene Council.
“Additionally, with the first of 78 million baby boomers reaching the age of 65 just last year, facility managers face the pressures of finding far-reaching solutions more quickly. Hence, solutions such as proper hygiene education among staff will continue to be needed and will become an even larger focus area for infection control.”
Healthcare-acquired infections are responsible for more than 100,000 deaths a year. They also have become a leading cause for hospital transfer of patients to long-term care and assisted living sites, Aiello says. And while the Centers for Medicare & Medicaid Services imposed financial penalties for HAIs in 2008, a recent Harvard study published in the New England Journal of Medicine showed no discernible reduction in infection rates.
Compounding the mounting challenge is that long-term care is frequently outgunned in the battle, says J. Hudson Garrett Jr., Ph.D., senior director of clinical affairs for PDI.
“Long-term care is typically limited in resources for infection prevention and control,” he says. “In many facilities, there is no dedicated human resource for prevention of healthcare-acquired infections. In addition, the typical training and continuing education provided for the infection preventionist in long-term care facilities is not always in alignment with the education for their inpatient hospital-based counterparts.”
With limited finances, long-term care facilities have to prioritize their spending, Garrett says. Infection control typically falls behind labor, nursing education and other key facility functions. Still, the risk of infection is high and operators need to explore all their options when it comes to creating an effective infection control program, he says.
Lorri A. Downs, RN, vice president of clinical services, infection prevention, and patient safety for Medline, agrees that long-term care has not historically had the resources it needs to ensure prevention. But she maintains this is changing as surveyors assess how infections are prevented from spreading.
“CMS determines the standards for certification in F-Tag 441, which states the facility must establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection,” she explains. “That is why APIC (the Association for Professionals in Infection Control and Epidemiology) recommended the LTC National Action Plan for the prevention of healthcare-acquired infections, designed to provide the financial, administrative and educational support needed to run infection prevention programs at the highest level.”
Because residents are elderly and often frail, they are highly susceptible to pathogens in their environment. Those posing the biggest threats are Clostridium difficile, Methicillin-resistant Staphylococcus aureus (MRSA) and E. coli bacteria, though influenza, bacterial urinary tract infections and viral gastrointestinal illness are also very serious, Aiello says.
Klebsiella pneumonia carbapenemase (KPC) is also an emerging threat of highly resistant bacteria that have “significant morbidity and mortality” associated with them, Downs says, adding that mortality at two weeks after detection is 47%.
Clostridium difficile – C-diff – is especially concerning because it is becoming more prevalent and virulent, Garrett says. The Centers for Disease Control and Prevention reports that up to 75% of new C-diff cases are seen in long-term care settings. C-diff also is recognized as the primary pathogen responsible for antibiotic-associated colitis and for 15% to 25% of cases of healthcare-acquired antibiotic-associated diarrhea.
“Because of the frequent administration of antibiotics to residents in long-term care facilities, Clostridium difficile is a tremendous risk for this healthcare setting since inappropriate or overuse of antibiotics is a primary risk factor for development of this infection,” Garrett says.
Antibiotic resistance is a growing problem that has been created over a generation, Downs says.
“The major concern is that we are not developing any new antibiotics, so we have very few and sometimes no options for treatment,” she says.
Catheter-associated urinary tract infections are another persistent problem, with E. coli being one of the most frequent pathogens isolated, Garrett says.
“Long-term care residents frequently have urinary catheters in place as well as incontinence, which dramatically increase the risk for development of infection,” he says. “Norovirus is also a pathogen that routinely causes outbreaks in facilities due to the extreme ease for transmission. The infectious dose is very small and this virus can quickly cause chaos, affecting not only the residents but also the healthcare delivery staff.”
Emphasis on hygiene has been a staple of infection control in long-term care and facilities do a decent job of instilling hand-washing and other cleanliness procedures in staff, Aiello says. Even so, she says they need to be more diligent in ensuring that staff complies on a consistent basis.
“While there is a high level of awareness surrounding the importance of hygiene, unfortunately there is not enough activity in place to impact current hand-washing rates and effectiveness,” she says. “The continuation and enhancement of education among staff, residents and visitors about proper hand hygiene is key to addressing this issue. It will also be important to have staff designated for infection control since it requires a great amount of effort and vigilance to keep outbreaks at bay.”
Staff and residents should know that effective hand-washing practices include a 35-second wash that covers all areas of the hand and forearms while using warm water and soap and then drying with a paper towel, Aiello says. The wash should be followed by an alcohol-based hand sanitizer if patient touching will occur after the wash or if the prior touch included possibly infectious material.
“The most innovative hygiene practices require a combination of proper education and the right technology to help ensure that those solutions are effectively used,” she says. “For example, touch-free towel dispensers help users avoid re-contaminating their hands as they maneuver through facilities. However, this might be difficult if individuals aren't washing their hands correctly in the first place, aren't using the right products and are not taking the right measures to ensure that their hands remain germ-free.”
Downs also stresses that facilities need to “get back to the basics” of prevention, meaning a renewed emphasis on hand hygiene, catheter removal, cleaning and disinfection and oral care.
“With the advanced medical care we now provide, we have lost sight of the basics,” she said. “Another common misperception is that infection prevention belongs solely to the infection control practitioner, when it really belongs to all of us.”
Aiello advises that emphasizing hand hygiene is indeed important, but adds that “it is how that message is conveyed that will effectively impact your audience.” She points to a recent study on hospital hand hygiene that found that healthcare professionals engage in greater hand hygiene when they are reminded of the health implications for patients and not just themselves.
“This helps puts their actions into perspective and hopefully will motivate staff members to wash their hands in order to keep residents healthy, which is why they chose to work in this field,” she says.
Proper infection control also means that staff should make a strong commitment to continual professional learning, Garrett says.
“Given the daily changes in the practice of medicine, the process of remaining updated can be quite overwhelming,” he says. “Approach residents as potential family members, treat them in a way that you would want to be treated, and commit to innovating clinical practice daily with the goal of targeting zero preventable infections.”
“There are some excellent and useful infection prevention solutions present in the marketplace, but that they are only valuable when properly used according to label instructions,” Garrett says.
For example, some environmental surface disinfectants have multiple contact times listed on the product label for specific classes of microorganisms such as vegetative bacteria, viruses, pathogenic fungi, and mycobacterium. But because it is impossible to determine what type of contaminant is present on the environmental surface, he says the user should utilize the longest contact time.
“Failure to do so could result in contamination with more resistant organisms being left behind, which could result in transmission of infection,” he says.
Overall, long-term care facilities are becoming extremely proactive at engaging residents and their families directly in their medical care, Garrett says. This is a significant, he says, because it represents a “holistic approach” to infection control.
“Infection prevention must be hard-wired,” for those involved in resident care, he says.
Battling HAIs in long-term care facilities
To effectively fight healthcare-acquired infections, the Association for Professionals in Infection Control and Epidemiology has issued the following recommendations and guidelines:
• Administrators of long-term care facilities should provide financial, administrative, and educational support for facility infection preventionists to ensure that their infection prevention programs are run at the highest level.
• Greater promotion of hand hygiene programs in long-term care facilities.
• Use of the National Healthcare Safety Network in long-term care facilities and consistent application of NHSN definitions through all agencies of HHS, including CMS.
• Implementation of an infection tracking system to prevent re-hospitalizations.