Nursing homes are in a constant state of war with stubborn pathogens. Diligently staying clean while contending with the latest infection control rules is no picnic.
Every day, staff are confronted with a myriad of decisions of what to clean and what to toss, and the process that got them there is ever fraught with risk and possible bad decisions. Cost and caregiving implications abound.
“Healthcare-associated infections pose a significant danger to residents and patients in post-acute care,” says Patricia Howell, RN, BSN, WCC, CFCS, clinical support manager for McKesson Medical-Surgical Extended Care. “Many patients are vulnerable to infections and are exposed to pathogens. Contaminated multi-patient use medical equipment and point of care testing devices that have not been properly cleaned and disinfected can create a substantial risk in the patient care environment.”
Disposables conversions
A cursory tour of most nursing homes would easily reveal just how few reusable items there are today. Notable exceptions, of course, include linens and bath towels, as well as certain personal care devices and durable medical equipment.
A plethora of disposable resident care items includes gloves of all kinds, wipes and incontinence products, as well as suture/staple removal kits and wound dressings, which should actually be disposed of even if their seals are simply broken, reminds Ellen Thompson BSN, RN, CWS, wound and product specialist for Gentell.
Disposables have brought convenience and sterile certainty to caregivers, and, arguably, diminished cross-contamination and infection risks.
They’ve also brought higher initial acquisition costs. That’s changed.
“Their availability, coupled with lower cost, have increased the use of disposable products and has also impacted infection control in long-term care communities in positive ways,” says Mary Madison, RN, RAC-CT, CDP, clinical consultant, long-term care/senior care at Briggs Healthcare, who recalls incontinence management products such as briefs, cleansing wipes and pads used on beds and chairs as being among the first wave of dominant disposables. “The cost of these kinds of items has decreased over the years and these types of supplies are now widely available as a result.”
Surprisingly, a significant number of nursing homes today still use [adult] cloth diapers, according to Howell.
“The belief is that [using cloth diapers] is better for the environment and the person’s skin,” she noted. “But, really, how clean is their laundry? It is expensive to launder cloth when you combine time and utilities. Disposable briefs technology has come a long way in the last 30 years and the wicking ability and ease of use is much better for the patient and staff.”
That said, few nursing homes would likely pine over the days of reprocessing devices like clunky table top sterilizers, says Madison as she recalled the challenges of sterilization earlier in her career as a skilled nursing caregiver. “I come from a time when we had autoclaves for sterilizing equipment in nursing homes,” she says, musing how that statement would “show my age.”
“We spent hours every day sterilizing the equipment we needed to use,” Madison adds. “I can remember inserting a strip of special tape that told us if the proper temperature had been reached and thus the equipment was considered sterile. Thank goodness those days are over. The autoclaves were dangerous and often broke down, needing repair. I do not miss them at all.” She remembers autoclaves exploding from pressure malfunctions, as well as numerous nursing home staff suffering steam burns from their use.
The list of disposable care items today is seemingly endless, including everything from catheter insertion kits, single-use urinary catheters and urine specimen kits to suction catheters, oxygen tubing, catheter drainage bags and leg bags, and tracheotomy kits. Mercury-filled glass thermometers are another extinct device replaced by digital thermometers with disposable sheaths.
“There has been a shift from using metal bedpans and urinals since bedpan washers have declined in popularity due to the splashing of body fluids, which have the potential of generating aerosols (e.g., Norovirus, Adenovirus and C. difficile),” notes Janet Nau Franck, BSN, CIC, FAPIC, a leading industry infection prevention consultant. “Plastic bedpans, urinals and personal care products are cleaned after use, are not shared with other residents and are subsequently disposed after a period of time, according to facility policy and/or after discharge from the facility.”
Madison believes caregivers would welcome certain commonly used disposable items that, for now at least, are reserved for acute-care settings.
“I’ve seen disposable blood pressure cuffs, but haven’t yet seen them in long-term care,” she says. “I would certainly consider using disposable BP cuffs when residents are in isolation for MRSA, VRE or C. diff or residents whose auto-immune system is compromised. This disposable could prevent cross-contamination inside a nursing home.”
Meanwhile, certain types of reusable products are still competing with new disposable versions, and for perfectly valid reasons.
Take disposable and reusable cotton wash cloths for peri-care. “Again, how clean is their laundry?” Howell poses. “Disposable is much gentler on the skin.”
One drawback with some disposable cloths: the havoc they wreak on plumbing when they’re absent-mindedly tossed and flushed into toilets. (See sidebar for a look at that debate.)
One noteworthy product conversion happened fairly recently after a series of Hepatitis B infections in nursing homes. The outbreaks were later linked with caregivers who were using the same diabetes testing supplies on multiple patients. Testing confirmed that even cleaning fingerstick devices and glucometers with alcohol was insufficient to prevent blood cross-contamination.
The incidents led the Centers for Disease Control and Prevention, as well as the Centers for Medicare & Medicaid Services and the Food and Drug Administration, to forbid lancets, fingerstick devices, and glucometers designed for single-person use from being used on multiple individuals, and stringent cleaning and disinfection of multiple-user glucometers.
Best practices
For the most part, nursing homes are held to the same federal rules for cleaning and disinfection of reusable devices, which are generally embodied in the CDC’s “Guideline for Disinfection and Sterilization in Healthcare Facilities.”
Most patient care products that are intended to be disposable are normally labeled by the manufacturer as a single-use item, notes Franck, who is also co-editor of “The Infection Prevention Guide to Long-Term Care, 2nd Edition,” a new publication from the Association for Professionals in Infection Control and Epidemiology scheduled for May 2019 release. “Any item that cannot be adequately cleaned, or doing so would compromise the integrity of the product, should be pitched,” Franck says.
And that’s the rub for skilled nursing facilities — cleaning and disinfecting multiple-use devices with confidence while ensuring the act of doing it won’t alter or damage them for future use. It’s also clearly understanding the differences between sterilization and disinfection, which product or process to use, and when each process is applicable to each device.
Obvious candidates include products with cracks or tears that cannot be repaired or cleaned, according to Franck. This includes blood pressure cuffs, where moisture could be trapped and items could act as a reservoir of bacteria, viruses or fungi.
At the heart of the decision-making process are the so-called “Spaulding criteria,” the industry-accepted gold standard for disinfection and sterilization of patient-care items and equipment. Spaulding criteria classify each reusable item as critical, semi-critical, or noncritical based on the degree of risk for infection involved in their use.
In the simplest of terms, it is acceptable to clean and process certain devices with EPA-registered disinfectants, while other devices require the additional stringent step of sterilization. In all cases, regulators implore caregivers to follow manufacturer guidelines for cleaning, disinfection and sterilization.
That can sometimes pose issues.
“Following manufacturer’s instructions for cleaning and disinfectants is sometimes problematic for nursing homes,” says Howell. “Communication of information is vital, especially with staffing instability or changes in manufacturer directions not being funneled to the end-user.”
One recent illustration: a nursing home was cited during a state survey for using the incorrect disinfectant wipe on a coaguchek, a portable instrument for monitoring the needed dosage of anti-coagulants.
“Roche, the manufacturer of the device, discovered that when using the recommended wipes, the heater plate showed deterioration, which can cause issues with readings,” Howell says.
Roche issued a bulletin rescinding its earlier recommendation of a certain wipe, but the information was never communicated to the nursing staff who used the device.
Then there are the litany of everyday common sense practices that are passed down to nursing home staff through a huge myriad of channels.
One example: “Check treatment carts frequently for opened packages of one-time use dressings, and dispose of these,” explains Thompson. “Never take a multidose container, tube, bottle, etc. into a resident’s room. Use disposable containers, such as medicine cups, to hold ointments, powders, wound cleansers, dressings, etc. when taking dressing change supplies into a resident’s room.”
Reuse of disposables
Back in the early days when disposables were at the point of what many considered egregiously expensive, some providers tried cleaning the devices for reuse. The big problem came when harsh chemicals and disinfectants were used on resins and other materials they weren’t designed for.
It is generally not a good idea.
“Some facilities will reuse such items but that is extremely dangerous from a health and infection prevention standpoint as well as your facility’s and your individual liability,” says Madison.
“It is a common practice for some areas to attempt to conserve dressing supplies by saving unused sections of dressings for use on another wound,” Thompson adds. “This practice is not recommended, as the sterility of the package has been compromised and can result in an infection control issue for a facility.”
Franck says that in their efforts to contain costs, some facilities are laundering and reusing patient gowns as isolation gowns, using them in their facility as personal protective equipment. “Many of these gowns are not fluid-resistant or splash-proof after repeated washes and can cause body fluids to come in direct contact with healthcare personnel,” she notes.
“In my experience consulting to nursing homes, nursing home staff do not always clean and disinfect multi-patient use equipment properly,” says Howell.
“There are a multitude of reasons why they don’t — time, taking short cuts, lack of education and proper tools and disinfectants. Complexity of the equipment can also make them difficult to clean. The risk is becoming too great with emerging pathogens that pose serious and deadly health threats to not properly clean and disinfect and/or use disposable medical equipment, when possible.”
If a facility is considering reusing a disposable device, Franck suggests checking the FDA website for continual guidance and regulatory updates. The FDA provides two existing “Compliance Policy Guides” named “Reuse of Medical Disposable Devices.”
From the June 6, 2019 Issue of McKnight's Long-Term Care News
