As the long-term care industry progresses in its evolution toward more sophisticated clinical services, infection control specialists advise that now might be an opportune time to re-assess methodologies for disease prevention and control.
Of particular note are procedures involving catheters. Research from the Johns Hopkins University School of Medicine found that using checklists is effective in reducing infections while also saving money. In fact, the potential savings reportedly would add up to more than $3.5 trillion industry-wide over 10 years.

The Johns Hopkins program emphasizes changing a provider’s culture by using checklists to prevent errors and reduce costs. Additional safety precautions include “common sense” methods such as thorough hand washing, questioning when and if a catheter is needed, covering the patient and nurse or physician when a catheter is being inserted and seeking alternatives to central lines in the groin area.

Researchers reviewed records for 1.3 million intensive care unit patients over the age of 65 and analyzed the program’s impact when it was implemented across ICU departments in Michigan.

“Independent of whether they were in our program, mortality of all Medicare patients admitted to the ICU went down 10% compared to all 11 surrounding states. That is incredible,” said lead researcher Peter Pronovost.

While differences exist between the acute care and skilled nursing environments, taking a close look at catheter use is definitely relevant for long-term care, observed Deb Patterson Burdsall, RN, corporate infection preventionist for Arlington Heights, IL-based Lutheran Life Communities. She is also a member of the communications committee and editorial board for the Association for Professionals in Infection Control and Epidemiology.

“In my experience, any time a tube or device is inserted into a human body is a sensitive time for infection prevention,” Burdsall said. “As long-term care culture moves toward more complex care, and more devices like central venous catheters are present in long-term care, tools such as the checklist become increasingly important. Long-term care is accustomed to being a policy- and procedure-based industry. Our care community has had checklists for years. They work for frequent procedures, as well as procedures that are done rarely.”

J. Hudson Garrett Jr., Ph.D., director of clinical affairs for Orangeburg, NY-based Professional Disposables International, is a strong supporter of checklists.

“They have been scientifically proven to improve patient outcomes,” he said. “Cultural transformation is one of the most difficult changes to accomplish in the modern healthcare delivery system. In the long-term care environment, residents are exposed to a wide variety of medical catheters, including central venous catheters, peripheral IV catheters, nasal catheters, respiratory catheters and urinary catheters. Each of these catheters should be reviewed daily and assessed for medical necessity to prevent introduction of pathogenic microorganisms into the resident’s body. If basic infection prevention recommendations are adhered to by all healthcare providers, not only could healthcare costs decrease, but more importantly, mortality could significantly decrease as a result as well.”

Acute care vs. LTC
When examining how long-term care differs from acute care facilities in infection control situations, Deborah Heath asserts that “there are different rules and expectations” for each care site, including catheter use.

“Long-term care for years has not used catheters without a just cause,” said Heath, RN, director of nursing for Lenawee Medical Care Facility in Adrian, MI. “We must have a diagnosis to keep the catheter. Elders who are admitted to an acute hospital or an ER almost always have catheters without a reason. There are even guidelines on how to empty a catheter bag in long-term care.”

The key difference between acute care and long-term care is the environments themselves, says Saylorsburg, PA-based infection prevention consultant Steven J. Schweon, RN.

“Long-term care strives to promote a home-like environment and maintain maximum physical, mental, social and spiritual resident well-being,” he said. “The challenge arises with providing medical and nursing care in a home-like setting to residents who have numerous comorbidities and require care that was once given only in the hospital setting.

“While those who carry multi-drug-resistant organisms are placed in isolation at the hospital, a long-term care facility cannot generally confine these residents to their rooms for a prolonged period. Instead, interventions such as hand hygiene and covering wounds with dressings are used to prevent organism transmission,” he added.

Salah Qutaishat, Ph.D., director of infection prevention for Charlotte, NC-based Premier healthcare alliance, sees a variety of differences between hospitals and skilled nursing facilities for infection control.

“They differ in acuity, nurse-patient ratios and availability of diagnostic services such as clinical lab and radiology,” he said.

“The difference in population and acuity makes it difficult to apply hospital infection control policies to long-term care patients.”

Common infections acquired at both types of facilities are urinary tract, respiratory tract and gastrointestinal. Infections closely associated with long-term care include influenza, norovirus, Vancomycin-resistant enterococci, Acinetobacter and Clostridium difficile.

“Although transmission of influenza to patients at hospitals is possible, it’s very rare,” Qutaishat said. “There are several reports of devastating norovirus outbreaks in long-term care facilities, but nothing to my knowledge in hospitals. On the other hand C. diff outbreaks can occur at both long-term care facilities and hospitals at the same rate. Unfortunately, these infections may lead to increased use of antibiotics, which is a factor in developing serious infections such as MRSA.”

Re-thinking IC practices
While there have been many studies that focus on reducing infections in acute care, not enough attention has been paid to long-term care, points out Jane Kirk, RN, clinical specialist with Akron, OH-based Gojo Industries.

“Unfortunately, there are fewer studies that have focused on using evidence-based best practices in the long-term care setting to decrease infection,” she said. “While acute care best methods have been studied, there is very limited data for long-term care.”

Hand hygiene is paramount in every healthcare sector. Still, Kirk maintains that policies need to be revisited to ensure their effectiveness and offers the following example:

“Imagine a nurse is about to enter a patient’s room to do a post-op dressing change. Following the hospital’s ‘Clean In-Clean Out’ campaign, she stops and uses hand sanitizer from the wall dispenser located outside the patient’s room. She is still rubbing the sanitizer in as she enters the room and the patient and family members present are pleased to see her cleaning her hands. Before she can access the patient and the dressing in need of changing, she must move the bedside commode and put the patient’s bed rail down. At this point she is ready to begin the dressing change. Are her hands still considered clean?”

Not according to the Centers for Disease Control and Prevention and the World Health Organization, Kirk says.

“The nurse needs to clean her hands again before touching the patient,” she said. “In order to clean her hands she would have to put the bedrail back up, walk away from the patient and repeat the hand hygiene process using (hopefully) a dispenser inside the patient’s room. This scenario plays out many times during a healthcare worker’s shift.”

Keeping in touch
To be sure, all healthcare workers need to be cognizant of the surfaces they touch when it comes to proper hand hygiene, agrees David Anderson, product manager for Somerset, WI-based Apollo Bath.

“Hand washing is only as good as the next contaminated surface you touch,” he said. “The hand sanitizer is located outside the patient’s room, but the door handle is the next thing you touch.

There are other commonly touched areas that are huge areas for bacteria, including door handles, the across-the-bed table, bed rails, chair arms, sink, headboard, TV remote and cell phone. An infection control policy needs to pinpoint these common areas and establish a protocol that is strictly adhered to by everyone.”

Moving forward
As an LTC infection control preventionist, Burdsall works to make prevention the key.

“Infection prevention is emerging as an independent discipline,” she said, “with a knowledge base and skill set that overlaps but does not exactly mirror nursing and medical technology.”

Bath tubs are germ hotbed

The ring around the bath tub is more than just an unsightly stain — it is a layer of bacteria infestation that must be thoroughly removed in order to prevent the spread of infection, says David Anderson, product manager for Somerset, WI-based Apollo Bath.

“There is a difference between cleaning and disinfecting,” he said. “Wiping down the surface is not complete. You must use a quaternary sanitizing solution between each bath to strip away any occlusive material from bath oil, soap scum and organic matter that coat the tub. If you are not killing bacteria, you are just spreading it around for the next person to bathe in.”

One of the most common pathogens found in and around the bathing area is Clostridium difficile, which can be killed only with a bleach-water mixture, Anderson said.

The lowdown on infections

Healthcare facility-associated infections account for:
–An estimated 1.7 million infections annually
–99,000 associated deaths each year
–5% to 10% of hospitalized patients annually
–Nearly $20 billion in healthcare costs each year  

Source: Gojo Industries, 2011