Senior in hospital bed

Healthcare-acquired infections (HAIs) can be a scourge in any healthcare facility, but long-term care workers particularly have their hands full with them. Nursing home residents are particularly vulnerable due to their age and various comorbidities. 

In fact, according to the Centers for Disease Control and Prevention (CDC), approximately 1 to 3 million serious infections, including respiratory infections, urinary tract infections, skin infections and gastrointestinal infections, occur every year in long-term care facilities, and they are a major cause of hospitalization and death. 

“As we age, the body goes through many changes — one of them being a less effective immune system,” says Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of curriculum development for the American Association of Post-Acute Care Nursing. “There are many other changes of aging that when compounded by chronic disease, such as diabetes, COPD and heart disease, put the elderly at higher risk for a multitude of HAIs.”

Holly Montejano, clinical health liaison for PDI, agrees, adding that many residents of long-term care facilities have catheters — mainly central lines, peripheral lines and indwelling urinary catheters — making them even more vulnerable to infection. 

Certain medications — including chemotherapy, steroids and even antibiotics, also can increase one’s risk for an HAI. 

Given the small spaces shared by residents in long-term care, it is critical for skilled nursing administrators to take definite preventative measures to avoid HAIs, including ongoing staff and visitor training — and ensure proper reporting steps are followed when an infection does occur.

“Education is a key factor for all infection prevention initiatives,” Montejano says. “In addition to robust staff education, residents and visitors also need to be educated with infection prevention accountabilities to create a comprehensive culture of safety at the facility.”

Cause for concern

Some of the most recent and concerning HAI risks affecting long-term care facilities today include multi-drug resistant organisms (MDROs) and vaccine preventable illnesses, according to the Agency for Healthcare Research and Quality.

“Inappropriate or prolonged prescribing of antibiotics both in community physician practices and in the healthcare setting — along all continuums of care — have driven many organisms to develop resistance, rendering treatment difficult at best and ineffective at worst,” Montejano says. Stewart notes that antibiotic use also can cause secondary infections such as Clostridioides difficile (C. diff), a bacterium that causes diarrhea because of an imbalance of normal bacteria that is usually present in the gut. 

“Great care must be taken in skilled nursing facilities when it comes to this infection, as it can be transmitted very easily because the C. diff spores can live on inanimate objects,” Stewart says. “It also poses a great risk for dehydration, weight loss, falls and pain.” 

One of the most recent emerging HAI risks is a fungus known as Candida auris, which thrives on skin and can lead to invasive infections, says Rosie Lyles, M.D., MHA, MSc, director of clinical affairs at Medline. The bug — which has more than doubled in incidence from last year — can be identified only in specialized labs, and typically affects the sickest of the sick patients: those with tracheostomies, those who are ventilator-dependent, or those who have recently received antibiotics or experienced multiple recent hospitalizations. People infected with this potentially deadly superbug shed the fungus, contaminating beds, bed rails, doorknobs and windowsills, and are often colonized indefinitely.

Another superbug keeping clinicians up at night is Aspergillus fumigatus, Lyles notes. An airborne pathogen, this bug can lead to deadly infections, particularly in immuno-comprised patients, and there is not yet surveillance in the United States for this disease, nor is it reportable or notifiable, she says.

Montejano also notes that vaccine-preventable illnesses such as influenza, pertussis, pneumococcal pneumonia and shingles also pose an ongoing concern in long-term care communities.

“These diseases can be thwarted by a single shot, but if staff, facility residents and visitors aren’t educated on their importance, a gaping hole is left in successful infection prevention practice and infections can be transmitted easily within a facility,” she says.

Successful HAI prevention

When it comes to preventing illnesses in long-term care, taking a wide berth works best because this strategy doesn’t focus specifically on one pathogen, Lyles notes. Proper hand hygiene among healthcare workers tops the list of essential components for preventing the transmission of illnesses. Stewart adds that understanding which scenarios warrant alcohol-based hand rubs compared to soap and water is also important. 

“Infection prevention competencies must be included in every facility’s educational program,” she notes. “This goes beyond handwashing and should include when to use and change gloves, proper incontinence care, catheter care and how to properly use personal protection equipment when entering and exiting isolation rooms.”

Montejano also says that all staff must be trained in how to properly clean and disinfect in the healthcare environment, and provided ongoing reminders about practicing respiratory etiquette when coughing or sneezing, and not coming to work when sick. In addition, all staff should be required to receive all of their recommended vaccinations.

Nurses in particular need additional education focused on surveillance and assessment of HAI, appropriate use of antibiotics, the application of transmission-based precautions based on the HAI, and the facility’s policies in the case of an outbreak, Stewart adds. She also recommends that facilities consider adding an infection prevention surveillance component to daily rounds. 

“During these rounds, monitor staff to ensure they are washing their hands when indicated, following transmission-based protocols and washing equipment that enters more than one room such as blood pressure cuffs, life equipment or equipment used in therapy,” she says. Surveillance for nurses may include such things as proper use and cleaning of glucose testing monitor and wound care treatments, she adds.

In addition, many electronic health record systems are able to print reports such as diagnoses lists that will help pinpoint the most common infections and antibiotic use — sometimes even providing these details on a unit-by-unit basis, Stewart says. 

“This information can help administrators target where infection prevention education is needed the most to help avoid HAIs,” she says.

In addition, when infections do occur, it’s important to take action in long-term care to isolate those patients to avoid transmission, Lyles says. 

“To prevent cross-contamination, facilities should room patients who are positive with the same MDRO [multidrug resistant organism], as opposed to placing a patient who does not have an infection or colonize with the MDRO in a room with a patient who is positive of MDRO,” Lyles points out.

Staying vigilant

While infection prevention was an educated practice and not necessarily a dedicated position in long-term care for a long time, in recent years the Centers for Medicare & Medicaid Services has mandated more in its three-phase rollout of the Rules of Participation.

There has been more to address Quality Assurance and Performance Improvement (QAPI) implementation, infection control, compliance and ethics and physical environment. By November of 2016, long-term care facilities have been mandated to develop an infection prevention and control program; by November of 2017, facilities needed to implement an antibiotic stewardship program and just last month, phase three was rolled out, mandating that each facility employ an infection preventionist.

“With an infection preventionist onsite, communicable diseases can be reported to public health, hand hygiene and personal protective equipment adherence can be internally monitored to assist in reducing HAI transmission,” Montejano says. “Infection preventionists can also provide education regarding safe handling of linen to prevent organism transmission and track outbreaks to prevent future occurrences.”

Facility infection preventionists are also responsible for HAI reporting and tracking within the CDC’s National Healthcare and Safety Network (NHSN), the nation’s most widely used HAI tracking system. 

NHSN provides facilities, states, regions and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate HAIs, according to the CDC. Long-term care facilities that track and report HAIs through the network have the ability to see their data in real-time and share that information with clinicians, facility leadership, and other facilities and partners such as health departments or quality improvement organizations. NHSN is also the conduit for facilities to comply with CMS infection reporting requirements.

Healthcare facilities within a shared network can have greater impact working together than individually when it comes to infection control efforts, according to Lyles.