Laundry/Housekeeping Feature: Bugging out

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Infection control poses new challenges as 'super bugs' have begun to infiltrate facilities. But providers are fighting back.

Bacteria are everywhere. Don't look now, but a few are crawling around your desk and even up your nose. While not all are bad, the harmful kind can wreak human havoc, especially on older people with comprised immune systems.
Providers have been battling these microscopic creatures — no bans on torture here — since the beginning. They are not naive when it comes to germs' persistence and resilience.
But today, facilities are fighting a different variety of pest — ones that can survive traditional medical treatments. Such opponents demand a new combat strategy.
Safer cleaning and hygiene products — those that curb the likelihood of cross-contamination — offer one solution. Another tactic is establishing strict laundry and housekeeping procedures designed to protect workers and residents. Probably the strongest line of defense from infection is awareness about the spread of germs among employees, residents and their families alike.
Super bugs
Providers work daily to prevent the spread of more common illnesses, including the flu and urinary tract infections. But infection control has gotten tougher in recent years because of the widespread use of powerful antibiotics, experts say. MDROs (multi-drug resistant organisms) are one of the biggest challenges in infection control today. Sometimes called "super bugs," MDROs are resistant to many antibiotics. Two main types are MRSA (Methicillin-resistant Staphylococcus Aureus) and VRE (Vancomycin-resistant Enterococci).
Long-term care facilities have to pay special attention to MDROs because many residents come from hospitals where the use of antibiotics is widespread.
Yet another dangerous consequence of antibiotic use is the bacteria Clostridium Difficle (also known as C.diff). Antibiotics can suppress the normal bacteria in a person's intestines, causing this type of bacteria to flourish. The result can be violent diarrhea for the victim. Not only is diarrhea messy to clean up, but once the bacteria is in its spore form, the organism is difficult to kill.
It is similar to a plant seed, explains Kristen Thompson, technical service expert in the healthcare care division for Ecolab, a worldwide maker of cleaning and sanitizing products. "A seed can survive in dryness, but when it finds a place to grow, it can germinate. In its spore form it's very resistant," she said of C.diff bacteria.
Extreme bugs require extreme measures. Certain cleaning products have helped to stem the transfer of these organisms in a facility.
"Now we're getting highly resistant strains of bacteria that don't respond to antibodies, so the emphasis is on prevention," said Greg Bell, director of global external communications for Sturtevant, WI-based JohnsonDiversey, a sister company of SC Johnson of Racine, WI.
JohnsonDiversey introduced microfiber technology to healthcare markets over the last few years. Its MicroQuickâ„¢Microfiber Cleaning cloths are small machine-washable materials that can be used instead of regular towels. They are effective at getting rid of microorganisms and cross-patient contamination, according to the company.
Still other new products are available that help reduce cross contamination and contain bacteria. Pre-saturated wipes, which substitute for a solution and a rag, are a booming industry. Kimberly-Clark Professionals has been marketing its WetTask® wipes as a way to help to eliminate contamination that can occur when soiled rags are reused to wipe surfaces.
Related odor control products such as Arm & Hammer® Trash Can & Dumpster Deodorizer have also cropped up as awareness of infections has grown.
No replacement for hygiene
Stakeholders are aware that the efficacy of a product is no substitute for good hygiene in a facility.
"Certainly, we can come up with new products ... But it's up to the individual caregiver to perform
the procedure," said Ecolab's Thompson. "There's human behavior involved. What we need to do is not just develop the product but find ways to motivate and modify behavior to do the right things."
Hand hygiene is and always will be the best defense against infections, she and other experts assert.
One of the most important innovations in infection control over the last five years has been the rise of handwashing gel. These products, which allow workers to disinfect their hands without having to stop at a sink, may have contributed recently to increased hand hygiene compliance. But it's important to note that the hand sanitizers don't work in all situations, namely after going to the restroom or when hands are visibly soiled.
There are other standard precautions. Proper use of barriers, such as gloves, is key. Many workers misuse gloves. Overuse — not underuse — is a critical problem, said James Marx, an infection control consultant and owner of a company called Broadstreet Solutions.
Workers often keep their gloves on when they are feeding residents. That could be problematic, he said. Many employees also don't wash their hands after wearing gloves because they think the gloves are impervious to infection.
Yet another key precaution is healthcare worker vaccination. Many experts are dismayed that the Centers for Medicare & Medicaid Services' recent regulation on mandatory flu shots applied only to residents.
Only 38% of healthcare workers said they received flu vaccine, according to a study of 2000 data that appeared in the February issue of the Journal of General Internal Medicine. That percentage is far lower than the rate for nursing home residents.
When it comes to MRSA, it helps to be smart. If a resident enters a facility with a colonization of MRSA, the safest way to prevent it from spreading is to team up that resident with a roommate who is less at risk for contracting an infection, said Gail Bennett of ICP Associates, a Rome, GA-based consulting firm.
Proper procedures also apply in the area of laundry. For instance, negative airflow should travel from the clean air to the soiled area, says Kim Shady, North American sales manager for UniMac, a division of Alliance Laundry Systems, who consults with facilities on the proper design of laundry rooms. Also, there should be doors between the areas. A floor plan should be set up to accommodate these criteria.
Laundry machines today are also better at cleaning a wider variety of materials than before, another good sign for infection control, said Joel Jorgensen, director of sales and marketing for Continental Girbau. The company's washer-extractors feature microprocessor controls equipped with 20 present factor programs and 50 programmable cycles. Chemical representatives can program the machines to ensure the right amount of cleaning chemical is released at the correct water level, temperature and time of cycle.
There are a lot of misconceptions among long-term care employees when it comes to understanding the spread of germs, Marx said.
Many fear contracting AIDS or other insidious diseases at their workplace. He often tells employees they are at much greater risk of contracting the illnesses in their personal time if they have unprotected intercourse.
"They don't put it in perspective because then they have to take personal responsibility for their actions," he said.
When employees are working around residents with dangerous diseases, the same precautions apply as with other residents.
"Think about what you're doing with the resident," Marx says. "You shouldn't be in contact with anyone's blood. You should be wearing barriers. If you do come in contact with blood, you should wash it off."
Organizations are coming up with ways to encourage good hygiene practices among employees and residents alike. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) offers a program to members called "Speak Up" to encourage patients to be more informed about healthcare. Infection control is a component of the initiative.
Donna Caccavale, infection control practitioner for Parker Jewish Institute for Health Care and Rehabilitation of New Hyde Park, NY, tries to make procedures as easy as possible for employees.
"We don't need to be crazy about wearing masks," she said. "But we have to be smart about it and wear them appropriately."
She is constantly refining infection control procedures and equipment at the 527-bed facility. Recently, she changed over to a closed suction system for tracheotomies so there would be less exposure to infections for staff and residents. Last year, the facility eliminated the use of needle sticks for injections. It now uses only retractable sticks.
Still, she admits infection control is more daunting as organisms are growing smarter and faster.
"Every couple years, it seems there is something else new to worry about," she said.
Bugs in the system
Despite new technology and industry-wide awareness of proper procedures, infection control ranks among the top 10 deficiencies on state surveys. One major problem plaguing providers is turnover among infection control personnel. Infection control practitioners often are given multiple responsibilities within a facility. And when they leave, the facility has to train a new person. That often becomes a vicious cycle of training, said Bennett of ICP Associates.
Part of the problem is the regulations. While they require an infection control program, they don't require a person who has training in infection control and prevention. That is why Marx of Broadstreet Solutions stays busy.
"I give them expertise that they lack," he said. "I help them maintain their program."
A good program should include surveillance of infections and reporting; education of the residents, infection control person and staff; and an employee health program, said APIC's Arias.
The key to better infection control is a solid program, Bennett added.
"Infection control has got to become an institutional priority in long-term care facilities, starting with the administrator or CEO," she said. "When it becomes a priority, we've got to give the resources to the infection program that are necessary to do a good job."

The Ozone Alternative
Providers looking for a new way to reduce the spread of infections might want to consider adding ozone to their laundry cycles. The gas has been touted over the last few years as an effective way to kill infections, including super bugs.
It kills germs faster than chlorine, according to Mark Moore, CEO of Lexington, KY-based ArtiClean, whose ozone systems connect to traditional washing machines. Only fluorine is more powerful as a disinfectant, he said. (Ozone, which consists of three molecules of oxygen, is created when oxygen is exposed to electricity or ultraviolet light.)
Awareness of ozone is beginning to catch on, Moore said. Between 50 and 75 long-term care facilities use his ozone system across the country.
"Five years ago, no one wanted to listen to you," Moore said. "They thought you were telling a line of bull."
Ray Kelly, director of environmental services for Oakdale Nursing Home in West Boylston, MA, said he has noticed few infections like C.diff and MRSA at his facility since it started using the Aquawing ozone system about three years ago.
Another incentive is energy savings, companies say. Unlike typical laundry machines, ozone uses cold water and is more effective at 60°F than at 160°F, according to Ralph Daniels, owner of Aquawing, which is based in Auburn, NH. As a result, the systems help facilities save significantly on natural gas costs. They also use fewer chemicals, companies say.
Advocates say other positive attributes of ozone are whiter, fluffier and fresher-smelling towels and less wear and tear on linens.
One downside is cost – companies charge about $500 a month for rental of the systems — but many facilities quickly recoup the fees, Moore said. Facilities also should make sure ozone companies receive state approval for their systems.
The Centers for Disease Control & Prevention does not have guidelines regarding the use of ozone in laundry. Also, the proper temperature for laundering is still unresolved, the
CDC said.

Bug prone
Conditions that may predispose residents to infection:
∑ Diabetes
∑ Dysphagia
∑ Chronic immobility
∑ Pressure ulcers
∑ Indwelling urinary catheters and other indwelling devices
∑ Poorly controlled diabetes
Source: Jacqueline Vance and Kathleen M. Wilson, 2001.

Preparing the home front
Experts say a good infection control program should contain the following elements:
∑ Surveillance to identify infections in residents
∑ A system for detection, investigation and control of outbreaks
∑ An isolation and precautions system to reduce transmission risk of infectious agents
∑ Infection control policies and procedures
∑ Continuing education in infection prevention and control
∑ A resident health program
∑ An employee health program
∑ A system for antibiotic review and control
∑ Disease reporting to public health authorities

Source: "SPECIAL COMMUNICATION: Infection prevention and control in the long-term care facility," Association for Professionals in Infection Control and Epidemiology Inc., and the Society for Healthcare Epidemiology of America, 1997.