Lessons learned

It’s little wonder infectious disease experts are shouting that long-term care providers can’t afford to take flu season lying down.

Consider these facts: Seniors age 65 and older account for roughly 90% of all influenza-related deaths, and the 2007-2008 flu season proved to be one of the deadliest in recent years.

Certainly, last year’s influenza vaccine contributed to a higher rate of flu-related morbidity and mortality. It proved largely ineffective because of a less than optimal match against two of the three circulating viruses.

Although the Centers for Disease Control and Prevention and other collaborative health agencies accurately predict the flu strains likely to circulate and cause illness that season between 70% and 90% of the time, flu seasons’ overall unpredictability means there’s no iron-clad guarantee of vaccine effectiveness. The 2007-2008 flu season, which peaked at 9% of all reported deaths in March and remained above an epidemic threshold for 13 consecutive weeks, served as a valuable lesson to long-term care providers. It illustrated  that even though the influenza vaccine is a vital component of a flu prevention program, it can’t be viewed as the sole approach to countering infection in residents and staff.

“For [the elderly], even those who may be otherwise functioning well, if they get the flu, it can really be the straw that breaks the camel’s back. It can knock them down very quickly and make it difficult for them to recover,” noted Diane Heasley, RN, CNS, MSN, vice president of clinical services for DermaRite Industries LLC, Paterson, NJ. “That’s why it’s so important to take an aggressive, multi-level approach to influenza.”

It’s been said that the best defense is a good offense, and infection prevention experts contend that’s certainly the case when targeting the flu. 

As a first and most important line of defense, the CDC recommends annual flu vaccines for healthcare workers and those 50 and older. Even though the vaccine may be less effective in the elderly (particularly those 65 and older), it is still recommended in the senior population because it can lessen the severity and duration of the flu, even if the vaccine is not optimally matched to predominant circulating viruses.

“The flu vaccine is still the best way to protect against the flu,” noted Nancy Cox., director of the CDC’s Influenza Division. Fortunately, this year’s vaccine is expected to be more on target than last year’s, and Cox assured that the CDC has an all-time high supply of vaccine this season.

Vaccination success and widespread compliance relies heavily on accessibility and ongoing education. If it’s difficult for staff (including volunteers) and residents to receive the vaccine, or if they mistakenly believe that the vaccine will make them sick, they often will forego it, explained Patricia Rosenbaum, infection preventionist and spokesman for the Washington-based Association for Professionals in Infection Control and Epidemiology.

Rosenbaum recommends aggressive educational initiatives that begin months before flu season strikes (ideally in summer) to properly inform long-term care staff, residents and their family members about the importance of flu vaccination.

She’s also seen success with “flu vaccine carts” that can be easily transported to staff and residents directly on the units, as well as friendly vaccination competitions amongst units to further boost compliance. 

“It’s a good idea to impress on everyone, including [those in administrative positions], the importance of vaccinations,” she says.

People tend to follow the lead of authority, according to Rosenbaum, so if those in administrative positions are vaccinated and doing their part, others often will follow their lead.

Although it’s ideal to receive the vaccine prior to the onslaught of flu season, Cox explained that because flu season can last into spring, getting vaccinated in December or even later can still protect against influenza.

If the complications stemming from influenza weren’t enough of a concern, seasonal flu also can lead to secondary infections, including Staphylococcus aureus, which further increases morbidity and mortality in the elderly. To curb those risks, long-term care providers should actively promote wellness amongst residents and staff. This includes comprehensive health assessments and proper disease management, and ensuring adequate hydration and nutrition throughout the year, not just during flu season.

Heasley suggests hosting educational in-services often during the year to educate staff, visitors, family members and residents on how they can improve their health and boost their immune system, and help prevent infection through proper infection control practices and respiratory etiquette.

“Healthy residents mean better outcomes when flu season arrives. But you won’t be effective if you wait until flu season hits. Wellness is something that should be a priority year-round,” she explained.

The same can be said for adherence to infection control standards.

“Hand hygiene is really the number one defense,” stressed Rosenbaum, who recommends facilities provide gel hand sanitizers to promote hand hygiene compliance.

Educating families on the importance of hand hygiene is equally important, she said, as is training assistants and other caregivers to clean residents’ hands frequently with a gentle, pH-balanced cleanser that won’t break down the acid mantle of the skin. 

“Residents come in contact with many things. They walk up and down hallways, participate in group activities and touch many things along the way, including each other, so keeping their hands and the environment clean is very important,” Rosenbaum added.

Because even the most aggressive and prepared facilities will still battle seasonal influenza to at least some degree, it’s imperative that policies are in place to limit the spread of infection. Following contact and droplet precautions, which includes proper handwashing, glove and mask wearing, and educating on the importance of covering one’s mouth and nose with a tissue and avoiding touching eyes, nose and mouth, can greatly reduce the risk of acquiring and spreading influenza. 

Diligent symptom monitoring and infection surveillance is equally essential for curbing influenza infection and outbreaks in long-term care because it heightens awareness and provides a clearer picture of who has contracted the illness, according to Rosenbaum.

She encourages facilities to keep the entire staff informed of influenza cases and outbreaks—and immediately alerting the medical director so he or she can determine whether antiviral treatment should be administered.

“If a resident is suspected of having influenza, immediately follow droplet precautions and do your best to keep them confined. Maintaining spatial separation of three to six feet is ideal,” Rosenbaum said, noting that in the case of shared rooms, it’s a good idea to separate residents with privacy curtains, while alerting residents, staff and visitors about the need to follow respiratory droplet precautions.

Anyone coming within three to four feet of a sick resident should also wear a mask, and in cases of influenza outbreaks, it may be necessary to suspend activities and meals in dining rooms to further limit spread of infection.

Technology also can play a positive role in influenza prevention. For facilities that have them, Heasley recommends the use of negative-pressure isolation rooms, and some infectious disease experts also are touting the positive effects of technology that can eradicate microbials in the air and on surfaces.

“We think long-term care facilities are working hard to prevent infectious outbreaks using standard infection control protocol. The shortfall is that facility and corporate administrators are not thinking outside the box [and] thinking of technology as a source of protection,” said Lin Cochran, vice president of operations, AirScrub Systems by Clean Air Systems Engineering Inc., Aiken, SC. “Good housekeeping and fastidious infection control protocol is not enough.” 

The AirScrub System, which works with facilities’ existing air handling equipment, kills microbials in the air and on surfaces by blowing environmentally-friendly oxidizers into the facility via air supply ducts. The costs associated with managing and treating just one outbreak far exceed the cost of the system, Cochran added.

Still, Heasley contends that when it comes to effectively and inexpensively minimizing the spread of influenza, common sense still reigns supreme. 

“If anyone is truly sick, tell them to stay away. I know this goes against many facility policies—because many don’t have sick policies, especially for new employees—but it’s important to realize that the worst thing a caregiver can do is come to work sick,” she stressed. 

During her tenure as nursing home administrator, Heasley required sick staff to call in directly to her and then pay a visit to the emergency department to confirm that they had the flu and how many days they needed to recuperate. The facility would pay for the emergency department visit for new hires who didn’t yet have insurance.

“Not only can sick staff [infect] the residents they can also get other caregivers sick,” Heasley said. “We need to recognize that healthy staff means better care for residents.”