The swine flu factor: this latest pandemic highlights the importance of infection control in nursing homes

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Many nursing homes fail to meet hand-washing guidelines, Joint Commission finds
Many nursing homes fail to meet hand-washing guidelines, Joint Commission finds
All the jittery nerves among staff in long-term care facilities of late are understandable, given the H1N1 (swine flu) outbreak and  its potentially deadly impact. But the contagious virus notwithstanding, a flu epidemic in a nursing home or other eldercare community ranks among the top causes of administrators' sleepless nights.

Yet by following well-established procedures and adhering to ordinary “common sense” precautions, long-term care facilities can, and did, safeguard their residents and staff. It holds true for just about any pathogen that makes its way to the front door, infection control experts say. Fortunately, although the rapid spread of swine flu caused an inundation of media stories and dire predictions, this latest viral strain didn't pose any extraordinary threat to those already following proper infection control guidelines.

Because long-term care providers are used to being on guard against pathogenic incursions, their alert level is already high for the persistent threat of methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile (C. diff). Especially challenging is detecting the transfer of the nosocomial-borne MRSA and C. diff in residents coming and going from the hospital, infection control specialists say.

Hidden dangers

Latent germs within new residents transported from acute-care settings present the biggest dilemma, says Jo Whitson, president of Aiken, SC-based Clean Air Systems Engineering (CASE).

“It would not be uncommon for a pathogen that is colonized in the patient and not yet been identified in the hospital to travel to the long-term care facility,” she says.

“Hospitals will treat those with active infections and some hospitals will treat patients who are colonized before returning them to the long-term care facility,” Whitson adds. “But if the pathogen has not been identified, then the patient will be returned to the long-term care facility infected with the pathogen, which increases the likelihood of passing the pathogen on to other residents.”

In tracking the back-and-forth cycle, CASE—maker of the AirScrub System—has determined that approximately 30% of long-term care residents are colonized with MRSA and of these, one-half will convert into an active infection. Further, Whitson observes that more patients are coming from long-term care facilities with multi-drug resistant organisms than in the past.

Screening paramount

Intake is the primary shield against disease entry into a facility and it is at this initial point of contact where staff can make the biggest difference, according to Janet Franck, RN, an infection control consultant with Chicago-based Consulting Professionals.

“It is critical to perform a complete physical and history of each patient when they return from the hospital,” she says. “It is also essential to have good communications with the hospital to make sure they have done a thorough assessment at their end. At the time the resident returns, the admissions nurse should conduct a complete check of the patient to look for telltale signs, such as fever and coughing.”

On the acute care side, Whitson says more hospitals are screening patients for MRSA on admission by performing a nasal swab – a procedure not generally done by long-term care facilities.

“If the swab is positive for MRSA colonization, an attempt at decolonizing those individuals can be instituted,” she says. “However, this can be a costly procedure and therefore most long-term care facilities do not screen their prospective or returning residents.”

Franck worked at the Toronto hospital where the severe acute respiratory syndrome (SARS) outbreak first occurred in 2003 and says diligent investigation pinpointed factors such as fever that linked the cases together.

“There were other signs, too, but elevated temperature was the key to identifying SARS,” Franck says. “They should do the same now as they did in Toronto—check for temperature and other symptoms of staph or the flu. It is about being vigilant with screening and hand hygiene.”

Who to check

Franck stresses that the focus should not just be on transported long-term care patients, but on all visitors to the facility.

“Everyone should be checked for possible symptoms,” she notes. “Every facility should post clearly written signs that indicate if anyone shows signs of fever or respiratory infection, they should refrain from entering and return at a later time.”

Whitson concurs that hand hygiene is the most effective weapon in fighting the spread of disease, but adds it is not being done often enough.

“Current infection control protocol is a human-based activity and let's face it—humans make errors,” she explains. “According to the Centers for Disease Control and Prevention, less than half of healthcare professionals adhere to correct hygiene protocol, including hand washing.”

If flu is suspected, the American Medical Association  recommends wearing surgical masks, gowns and gloves.
Overall, the best strategy to end the cycle of pathogen traveling, infection control specialists say, is awareness.
“It's about being conscientious and studying the patient's condition,” Franck says. “If people are practicing standard precautions, they should feel very comfortable about accepting all residents unless they show overt signs of illness.”

Technology's role

Beyond staff interventions, facilities can implement mechanical and automation technology to assist in keeping germ infestations at bay. CASE's AirScrub System is designed to work in tandem with the building's existing air handling equipment. Depending on the size and configuration of the air handling equipment, CASE custom designs a system to improve air quality issues by eliminating odors, bacteria, viruses and mold.
Cleaner air translates into healthier residents, Whitson contends.

“After three years with our AirScrub system, an Alzheimer's facility has had no cases of pneumonia and no deaths from any communicable disease,” she says. “Another facility reports only three residents became sick with Norovirus after exposure by a visitor. The same visitor infected another facility in the same town and that facility was forced to shut down for over a week because almost everyone, including staff, contracted the virus.”

In the wake of the H1N1 outbreak, Atlanta-based Eclipsys created an automated tool designed to rapidly diagnose communicable disease like flu. Working in conjunction with the company's Sunrise Clinical Manager system, the new program helps clinicians identify, isolate and treat patients suspected of having the H1N1 virus.

“We are uniquely positioned to help minimize the negative impact of this pandemic and have responded by assisting our clients in better isolating and managing H1N1 symptoms to stave off acute states and slow or eliminate the virus' spread across populations of patients,” says Richard P. Mansour, MD, Eclipsys' chief medical informatics officer and vice president of product innovation.