As surveyors and regulatory agencies turn sharper eyes to nosocomial infections, long-term care providers are finding their infection control policies and procedures more intensely scrutinized.This heightened focus is helping shed light on infection control-related shortcomings. For some facilities, the list of errors is lengthy—and many aren’t passing muster on even the most basic infection control practices, experts warn.
“I believe that most healthcare workers want to do the right thing, but at the same time, we know that some are falling short. Often, it’s because people are rushed and [resources] and training are scarce,” says Michael Schmidt, Ph.D., a microbiologist at the Medical University of South Carolina in Charleston.
Statistics underscore the need for greater diligence. Roughly 1.5 to 2 million nosocomial infections occur in long-term care residents each year, which equals one infection per resident annually, according to a 2007 study published in Clinics in Geriatric Medicine. Further, many infections that occur in the vulnerable long-term care population are caused by multidrug-resistant organisms, and for every person infected with an MDRO, many more are asymptomatically colonized with these organisms, which means they serve as reservoirs for infection transmission.
Incontinence, acute conditions, and close living quarters add to the challenges, as does frequent staff turnover, which can impede training and consistent adherence to proper practices.
All hands on deck
Despite myriad guidelines, studies, seminars, and public service announcements touting hand washing as the most important step in infection prevention– and despite statistics that show roughly 80% of infections are a consequence of touch—many healthcare workers are still missing the message.
“Studies show that less than 50% of healthcare workers are hand washing-compliant,” notes Rhonda Lemmo, RN, CNOR, manager at Molnlycke Health Care, Denver.
Part of the problem is that employees may not fully understand what compliance really means. “If they’re washing their hands, they may assume they’re being compliant, but that’s not always the case,” explains Joe Kingsley, president of Moab, UT-based Glo Germ Co.
Fifteen- to 20-second washing with soap and water is key, but many aren’t washing that long, he says, and some aren’t cleaning their entire hands. Employees should be washing up to their wrists and also paying special attention to spaces between fingers and where the thumb meets the hand, Kingsley says.
Skin dryness and chafing that can stem from frequent washing also require careful attention.
“It can be painful to wash hands when they’re dry and cracked, and that may cause some to wash less often. But even if people continue to wash as they should, bacteria will find shelter on chapped hands,” he explains, noting that the roughed-up skin makes it more difficult to wash away germs. “I always recommend healthcare workers select a good, high-quality hand lotion that works well for them and then use it at least two to three times a day to keep oils replenished. It’s a simple step that can improve comfort and hand washing effectiveness.”
Knowing how to wash and care for hands is just one hurdle, however. If washing isn’t frequent enough, microorganisms rapidly multiply and spread, regardless of how well and how long people are scrubbing at the sink.
According to the Centers for Disease Control and Prevention’s Guideline for Hand Hygiene in Health-Care Settings, hands should be decontaminated before direct patient contact, eating, insertion of catheters or other invasive devices, and donning of gloves. Decontamination also is recommended after contact with a resident’s intact skin; contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings; contact with inanimate objects in a resident’s immediate vicinity; toileting; and glove removal.
Schmidt says that while proper hand hygiene takes time and may seem tedious for some employees, its importance simply cannot be overestimated.
“Metaphorically, hands are a lot like Velcro. Each time we touch something our hands are picking up and then depositing microbes,” the microbiologist emphasizes. “This is why frequent, proper hand washing is so critical.”
To reduce infection transmission, residents, visitors, vendors, and others who enter the facility also should wash properly.
“Simple measures, such as having a hand hygiene station immediately available upon entry to the facility, with visible instructions demonstrating proper hand hygiene, makes a tremendous impact in reducing the numbers of community microorganisms entering the facility,” notes Hudson Garrett, Jr., Ph.D., director of clinical affairs for Orangeburg, NY-based PDI Inc.
At Levindale Hebrew Geriatric Center & Hospital in Baltimore, every employee, regardless of his or her position, spends three days in orientation training to learn infection control basics. Staff, visitors and residents are encouraged to disinfect their hands via instructional signage and the placement of hand washing stations located in common areas, such as near elevators and at the dining room entrance.
“We also have ongoing observation by people on assigned units so they can observe all different [types] of staff to promote compliance, and it’s been very effective,” says Mary Lindenmuth, RN, performance improvement/safety specialist at Levindale. “We’re aiming for more than 80% compliance.”
Educating staff and visitors about proper use of alcohol-based hand gels is also critical, Lemmo adds. “If you’re using alcohol gels, you need to apply enough to really get the whole hand, and then allow a full minute for the alcohol to dry,” she says, noting that many make the mistake of waiting only half that long.
While alcohol-based gels offer immediate kill, sources agree that its use does not negate the need for traditional washing. “You still should be washing your hands at least every hour,” Kingsley says.
Staff, residents and visitors can get more mileage from hand washing by using an emollient cleanser with chlorhexidine gluconate (CHG), which offers extended microbial killing (even for methicillin-resistant Staphylococcus aureus) for up to six hours. As Molnlycke’s Lemmo explains, the product is activated after the cleanser is fully rinsed with water. Some facilities provide CHG hand wipes for residents in dining halls, activities rooms, and even at the bedside, she says.
Staff should be aware, though, that some alcohol sanitizers are CHG “Kryptonite,” so to speak.
“Some alcohol hand rub formulas can deactivate CHG,” Lemmo notes, “so make sure you have the right formulation.”
Proper glove handling
Because gloves attract microbes in a way similar to bare skin, they, too, must be used properly.
Washing hands and changing gloves between each patient is essential, and more diligence is needed, experts say.
Reaching into pockets or even moving a wheelchair or bed tray with gloved hands and then using those same gloves to tend to a resident is a no-no, yet many employees make this mistake. A dropped item, such as a pen, that’s retrieved from the floor with a gloved hand also is cause for concern.
“If gloves become contaminated, they must be removed, hands must be washed and then new gloves must be [put on],” says Lindenmuth.
Masks, eye protection, face shields and gowns also play an important part in infection prevention. Each should be worn by all staff for all residents—regardless of diagnosis or presumed infection status—when contact is anticipated with blood, body fluids, secretions and excretions (including feces and urine, but excluding sweat), non-intact skin, and mucous membranes.
Many long-term care employees fail to recognize the infection risks related to work clothing. It’s not uncommon for staff to wear their scrubs to and from work, and everywhere in-between.
“Scrubs can provide a vehicle for infection transmission. In many cases, the fabric allows bacteria to adhere to it and, therefore, staff members could be serving as human reservoirs for these bacteria and carrying them throughout the facility,” Garrett says.
Scrubs should only be worn at work. If on-site laundry services aren’t provided, staff should launder their togs in hot water after each use—even if they aren’t visibly soiled. White scrubs that can be bleached are ideal, “and only scrubs should be laundered together,” adds Michele Bell, RN, BSN, national clinical director, SCA Personal Care, Bowling Green, KY.
Carrying personal items in scrub pockets also can spread infection.
“Personal property, whether it’s keys or a phone, should not be on you,” Bell warns.
Even care-related products placed in pockets, such as a tube of cream, can increase risk of infection transmission. Touching the tube with a contaminated glove contaminates the tube.
Environmental surfaces are a common reservoir for infection, and once-daily cleaning isn’t always enough, especially where high-touch surfaces are concerned.
“The minute cleaning is finished, microbial contamination starts again,” Schmidt says. Within four hours of disinfection, the measurement of microbial burden on surfaces, such as bed rails, is back to its pre-disinfection levels, he notes. “Microorganisms will continue to grow and multiply, so the solution to pollution is dilution. The more we can reduce the number of microbes, the better. Among the best ways to do this is to take away the food that microbes need to survive and thrive.”
Dust, which is mostly skin cells, is one food source that should be routinely targeted. Staff also should avoid eating in clinical areas and nursing stations—a bad habit that not only can feed microorganisms, but also make employees sick by orally introducing infection-causing bacteria, says Lindenmuth. At Levindale, high-touch surfaces, such as computer keyboards, are outfitted with a fully cleanable cover; and telephones are cleaned and disinfected several times a day.
Experts add that routine cleaning of walls and privacy and window curtains also is prudent.
“These areas, along with visitor seating and objects visitors come into contact with can be a collection area for dirt and germs,” explains Brad Reynolds, category manager, Kimberly-Clark Professional, Roswell, GA.
Another problematic, yet oft-overlooked practice is reusing rags and mops between rooms. A closed container system with disposable wipes and a pre-mixed cleaning solution can reduce the risk of cross-contamination, he says.
Staff should be especially cautious with items that come in contact with residents’ mucous membranes and non-intact skin.
“Many times, a resident will pull the oxygen tubing from their nose and it’ll dangle on the floor or up against the side of the bed, and then it’ll be placed back in the resident’s nose,” Bell says. “This tubing should be disposed of and replaced.”
Residents and visitors should also be educated about these risks, and how to minimize them.
Be safe, not sorry
Designated equipment can go a long way toward reducing infection risks. Employees should use their own stethoscopes—and disinfect them after each use—and they should avoid sharing common resident care items, including towels, blankets and pillows.
“In long-term care, there tends to be a lot of sharing going on, but this is a good way to pass germs. If you’re going to share a pillow, be sure to change the pillow case,” recommends Denise Fitzpatrick, RN, MBA, senior vice president of clinical consulting for Marsh Risk Consulting in New York.
And don’t underestimate the importance of staying away when you are sick.
“If a resident is [infectious], it’s best not to expose them to others,” Fitzpatrick continues. “The same goes for employees and visitors. If you’re sick, please stay home. This is one of the simplest and most important things you can do to prevent cross-contamination.”