Healthcare Acquired Infection Prevention (HAI) in Long-term Care

The term Nosocomial Infection has more recently been changed to Health Care Acquired Infection or HAI, but I find Health Care Workers continue to default to using Nosocomial. In any case, a HAI or Nosocomial Infection, is one that develops 48 to 72 hours after admission to a healthcare facility, according to McGeer’s Criteria (McGeer’s, 1991)

Multiple factors contribute to the transmission of infectious organisms in hospitals, long-term care facilities and rehabilitation centers; they include the type of infectious organism, the patient’s proximity to the source of infection, the means by which the organism could potentially be transmitted  and the status of the patient’s immune system.

Ultimately, it is the responsibility of the facility to develop policies and procedures designed to interrupt the transmission of infectious organisms from the source to the patient and to maintain a strong Infection Control Surveillance program. That is where you, the DSD, Infection Preventionist, or DON, and your Infection Control Committee, come in. Preventing HAI in Healthcare Facilities CDC

References:

McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang E. Definitions of Infection for Surveillance in Long Term Care Facilities. American Journal of Infection Control 1991; 19(1):1-7.

PHIL ID # 10068
Photo Credit: Janice Haney Carr, Centers for Disease Control and Prevention

PHIL ID # 10045
Photo Credit: Janice Carr, Centers for Disease Control and Prevention

CDC Newsroom Image Library

 

 

ESBLS

ESBL
is the acronym for Extended Spectrum Beta Lactamase. If it sounds somewhat complicated it is; basically, ESBLs are bacteria that produce an enzyme capable of neutralizing the effectiveness of certain classes of Beta-lactam antibiotics such as, carbapenems, cephalosporins and certain penicillin derivatives. The end result is yet another type of Multi-drug resistant Organism (MDRO).

The bacteria are spread in the same way all organisms are transmitted depending on their site.  Those at highest risk are usually hospitalized patients who have been on extensive antimicrobial therapy and have already compromised immune systems.

What should be done about ESBLs in long-term care?

  • If you are new to infection prevention, be sure to locate your facility policy for MDROS in your Infection Control Manual.  Hopefully, the policy will be up to date and based on the evidence based guidelines and recommendations available to long-term care facilities in your state.
  • The CDC, your state Department of Public Health and APIC (Association for Professionals in Infection Control and Epidemiology) are the Big 3 support systems for Infection Preventionists. Visit their websites frequently.
  • If you aren’t sure or have questions, seek out the support of your DON, and the Infection Control Committee.
  • Together, you can review, update and sign off on a current policy.  As soon as appropriate, announce the presence of an updated policy for MDROs (including ESBLS) to the staff and educate them to its definition, treatment and potential precautions.
  • Standard Precautions are THE place to start; utilize Transmission Based Precautions for infections that cannot be contained. Think about that.

Is an ESBL in the urine contained in a Foley bag, a diaper or as a continent patient?

If the source of the organism is contained, the patient’s hands are clean, they are wearing clean clothes and want to socialize, could they be managed with Standard Precautions?  

What is the policy for your facility? Is your staff educated frequently to the principles of Standard Precautions?

CDC on ESBLS

 

UTI VS. Asymptomatic Bacteriuria

Situation
: One of the nurses tells you she has an elderly, asymptomatic female patient who has been diagnosed with three urinary tract infections in the past three months. The physician orders Levaquin each time he is called with positive culture results and orders repeat cultures when the antibiotic is completed. The cultures usually come back positive for E. coli.

What should you as the Infection Preventionist, do in this situation?

  • Confirm the nurses who have placed the calls to the physician have assessed the patient completely before calling
  • Confirm they have reported in detail, the fact that the patient is not exhibiting any signs and symptoms of UTI such as dysuria, flank pain, frequency, etc. 
  • In-service the nursing staff on Urinary tract infection; use Mcgeer’s Definitions of Infection for surveillance in long-term care facilities (A. Mcgeer, MD, et all, 1991) this is the standard used in most long-term care facilities. McGeers
  • Point out the differences between infection (positive signs and symptoms) and bacteriuria (the presence of bacteria in the urine with no signs and symptoms of infection).
  • Remind nurses of the association between inappropriate use of antibiotics and C. difficile disease.

You as the nurse,could call the patient’s physician, discuss the facts with him, ask if the patient could have bacteriuria and ask if he wants to continue current antibiotic therapy.

If there is no resolution to the problem you should contact your facility’s Medical Director and ask for their expertise and possible intervention. See Pub Med.org

 

 

 

 

The Infection Control Manual in Long-term Care/ Where is it Written?

In case you’ve never developed a personal relationship with your Infection Control Manual, and if no one has ever mentioned it, you should know you really do have one.

You might want to locate your manual sooner, rather than later, because this great white book should contain written policies and procedures (P & P’s)  or, the rules to the game of Infection Control in your facility.  Surveyors will ask you to locate it, when it was last updated, if it is compliant and if you are following your own policies and procedures (P & P’s).

A good place to begin looking for the Infection Control Manual you have never been formally introduced to is probably down the hall, in an abandoned office, on the bottom most shelf. With some diligence you might spot it leaning against thirty two other misplaced, dusty manuals of one kind or another. You will soon see they all look alike; they are usually large, white, three ring binders that at first glance, seem to have been deliberately designed to be indistinguishable from every other kind of manual.

There are Long-term Care facilities who are right on top of things and know exactly where their Infection Control manual is at all times. They may have invested in multiple copies, and occasionally one may even be found at, or near the nurses’ station, easily accessible.

Conversely, there are also those facilities that have no idea where to find their manual, or who have multiple editions from extraneous sources, such as labs they contracted with years ago and have long since lost communication with.

When vendors change, the manuals are usually dismissed in favor of the latest provider’s version.. and so the collection grows until one day, the unfortunate novice Infection Preventionist arrives on the scene, searching for the most recent, updated and compliant manual, only to be faced with an ongoing scavenger hunt.

The Infection Control Manual is more than a resource; its purpose is to contain the Infection Control Policies and Procedures of your facility. They are meant to be based on federal, state and local guidelines, mandates and regulations. These policies and procedures must be reviewed, updated and approved by the Infection Control Committee at least annually and more often as indicated.

In the case of a missing or non-compliant manual, once found, it may be in urgent need of revision. There are companies who produce Infection Control Manuals for Long-term Care and if the facility is a part of a large corporation, there is more apt to be help in the form of corporate Infection Control Policies and Procedures.

The Infection Preventionist needs to locate their facility Infection Control Manual, no matter what state it is in, as soon as possible. Once located, set about updating, editing and revising, with the help of any Infection Control Consultants you may have available to you, your nursing, staff and the Infection Control Committee.

Picture reference: Old Computers.com; manuals close up; (March 26, 2012)

APIC: Your Professional Association

 

This is the logo associated with the Infection Prevention and Control Professional Association known as The Association for Professionals in Infection Control and Epidemiology (APIC)

What is APIC?

APIC is the Infection Preventionists (IPs) Professional Association. I encourage any person who is in any way associated with Infection Prevention and Control to visit the APIC website and to also consider joining the organization.

What does APIC do? Visit the APIC website and take a look. 

Here you will find evidence-based and scientifically proven resources you will feel confident in using to support your Infection Prevention and Control program. There are many, many more resources available to you as well

APIC and the CDC work in concert with one another to provide the most consistent and up to date resources, guidelines and recommendations in the Infection Prevention and Control environment.  

Why become a member?

APIC members are comprised of nurses, public health professionals, physicians, epidemiologists and others who among other things, are involved with collecting, analyzing and interpreting surveillance data collected in their respective work environments. It makes sense to seek out others with mutual educational and professional interests in order to strengthen and support your role as an Infection Preventionist.

And one more thing…

Long-term Care Nurses share a common need to become actively involved in establishing scientifically based infection prevention practices. We need to collaborate with not only Long-term Care Nurses, but all member of the healthcare team to insure prevention of healthcare-associated infections (HAIs). Education is the answer. Do it for yourself; yes, it requires an additional personal investment of your time and a determination to become better prepared to practice in your profession. 

Reference: APIC website http://www.APIC.org

 

 

 

 

 

 

Latent TB: Newer, Shorter Treatment Options for Some

People who have been diagnosed with Latent TB may or may not go on to develop active infection according to the CDC. For this reason it is important to follow up on suspected conversions of residents and Health Care Workers in Long-term Care and in all other situations. After careful assessment, physicians may opt for treatment with antimicrobials.

In the past, traditional antibiotic treatment for Latent TB has been lengthy and often fraught with patient compliance issues. Subsequent to findings gathered from large clinical trials, the CDC has written new Guidelines with newer options for the treatment of Latent TB in some persons, depending on the patient’s medical history, immune system status, clinical presentation and physician recommendations.

Here is the link to the CDC’s: New, Simpler Way to Treat Latent TB Infection.

Retrieved February 22, 2012, from Centers for Disease Control and Prevention

 

Latent TB

Latent TB is the name given to persons who have been exposed to Mycobacterium Tuberculosis, but who do not show signs and symptoms of active disease, such as night sweats, persistent cough, bloody sputum, feelings of exhaustion, and weight loss; Latent TB patients are not infectious to anyone else but about 7-10 % will go on to develop full blown Tuberculosis at sometime during their lifetime, according to the Centers for Disease Control. Diagnosis of Latent TB Infection

In Long-term Care facilities a resident or health care worker may convert from a previously negative PPD test to one that is considered positive when they receive their annual PPD screening.  It is vitally important that the nurse responsible for the facility TB screening program is experienced and accomplished at both administration and interpretation of the results. Being a nurse does not necessarily infer the skills required to interpret redness, swelling, or indurations associated with TB testing. If a nurse reads the results of a PPD incorrectly this year, it could adversley affect the results of the annual PPD next year. Here is a link to the CDC Interpretation Fact sheet and Wall Chart for administration and Interpretation of the PPD. TB Interpretation Fact Sheets /PPD Wall Chart

Next: New treatment options for Latent TB

Reference: Picture by microbiologyinpictures.com/mycobacteriumtuberculosis16; February16, 2012 

Diary of an Outbreak

Here is a real example of just how virulent Noro Virus, the virus that causes Acute Gastroenteritis, can be. Visualize the chain of infection. This is a true story, in fact, it occurred in my own extended family.

Day one, A 20 month old baby girl (Sophie) in child care with 14 other young children 5 days a week, went to visit her Grandmother. During the 4 days of her visit, she also visited another family member with two children aged 2 & 3.

On day two of Sophie’s visit, she refused to eat and then suddenly began vomiting while in a restaurant. She develped diarrhea as well. Her symptoms lasted for about 12 hours, subsided and completely resolved the next day.

On the third day of Sophie’s visit,  4 adult women and the 3 small children gathered together at a Holiday Farmers Market. Remember, Sophie was now symptom free for 24 hours. They visited and spent the day together. That night 3 of the 4 women began vomiting violently; one had to go to urgent care.

On the fourth day, Sophie’s mother picked up the child and took her home; the next day she began vomiting violently as did her best friend who was visiting when the child came home.

The child had been symptom free for two days by then. From the time Sophie exhibited her first symptom, 7 people contracted the virus and were taken very ill.  We can only wonder how many others were infected at the Holiday Farmers Market.

Three days after all members of the family were symptom free; an uncle visited and spent the day with the family. No one was ill. The uncle left, flew home, and while on the plane, became ill with the same symptoms; this was now 7 days after Sophie displayed her first symptoms. Noro virus is very contagious.

Think of hospitals, long-term care facilities, child care facilities, schools, cruise ships, anywhere where people are in close proximity to one another; they are touching, sharing, eating and ultimately, ingesting the virus. It takes very little time to find you are in the midst of an outbreak.  Why?  Because the virus is transmitted via the oral/ fecal route, meaning the virus is shed orally and through the feces/diarrhea.

We can’t see the virus, but we unknowingly touch the same surfaces the infected person has touched and then proceed to ingest the organisms when we put our fingers or hands to our mouth. Infected food handlers transmit the virus as well. CDC Noro Virus Transmission by Food Handlers

There may be a vaccine on the horizon but there are many strains of Noro Virus, much like the flu.  CDC: Noro Virus and Vaccine

For now, the only way to prevent infection is by practicing scrupulous hand washing and even then, where children are concerned, it’s all but impossible to contain the transmission of these highly contagious organisms because children play so closely.  

Adults may be able to avoid the virus if they are meticulous about hand washing and sanitizing the environment, but in many situations, attempts at prevention come too late.

The Infection Control Professional in Long-term Care

An Infection Control Professional working in Long-term Care is also referred to as an ICP (Infection Control Professional) or Infection Control Nurse. More recently the term Infection Preventionist has been introduced to describe the position. ICP’s are usually required to be a licensed Registered or Vocational Nurse, depending on state regulations and in Long-term Care, the job of Infection Control Nurse is frequently assigned to Staff Developers, adding to their already endless list of responsibilities. This is a big job and really, out of fairness to all concerned, deserves to be filled with someone with at least some background in Infection Control.  Consider some of the duties assigned to the Infection Preventionist:

Surveillance: In infection control, surveillance is the term used to describe the function of observing, gathering, investigating and reviewing information about the patient as it pertains to infection prevention and control.

Patient Assessment: Accurately reporting signs, symptoms, and changes in condition and initiating isolation precautions as indicated.   

Tracking and Trending: Tracking and trending information gathered from surveillance; Practicing outbreak prevention and investigation, monitoring rates of infection and communicating findings in the form of verbal and written reports.  

Orientation and Staff Education: Educating staff, patients and families to Infection Prevention. Monitoring staff compliance with basic infection control principles such as; hand washing, isolation, transmission based precautions, and use of personal protective equipment (PPE).

Monitoring Antibiotic Usage:  Reviewing and reporting antibiotic usage and trends of antibiotic resistance reported in antibiograms.   

Revising Policies and Procedures: Participates in updating policies and procedures needed to maintain compliance with current recommendations from agencies of the federal and local government such as; OSHA, the CDC, state and local departments of health. 

Conducting Environmental Rounds: Monitoring department compliance with Infection Control guidelines; conducting environmental rounds and consultation as needed.

Monitoring Employee Health:  This may or may not be the direct responsibility of the Infection Preventionist. Responsibilities include annual physicals and tuberculosis screening for new hires and employees, offering influenza and Hepatitis B. vaccines, keeping accurate employee records, initiating workplace restrictions if indicated, becoming familiar with OSHA regulations and educating staff to Infection Control and Blood Borne Pathogens standards.

Each facility will have their own policies and procedures regarding the expectations of the Infection Control Designee. Responsibilities may be shared but usually are not. Hopefully, the Infection Control Professional will be given the support they require to do their job efficiently and with satisfaction. 

 

MDRO’s in Long-term Care

I

n 2004, the Centers for Disease Control (CDC) developed a 12 steps campaign to prevent antimicrobial resistance in long-term care.  Step # 4 states “Broad Spectrum Antibiotics must be targeted to known pathogens.” Broad Spectrum Antibiotics are frequently ordered in long-term care. The physician is usually not on the premises when they receive a call that a patient has a complaint of burning when they urinate, they seem more confused than usual, or any number of vague complaints. The physician may not even know the patient; they may be on call for another physician. Are these symptoms, as reported, relative to a true change in condition?

Is the physician getting an accurate picture of what is going on with the patient? When the physician does not have a clear picture of what might be going on, the Broad Spectrum Antibiotic is a tempting choice to make; It may be prophylactic but it treats multiple organisms and buys time until labs are ordered, drawn and resulted. But, misuse of Broad Spectrum Antibiotics has also caused the resistance that is now actually limiting a physician’s choice for treatment.

Communication from nursing staff to physician could be one of the most important steps toward preventing the misuse of antibiotics. Treatment of suspected infections must be supported by accurately reporting pertinent data gathered by nurses experienced in using established surveillance tools. Nurses need encouragement and education to develop familiarity with established criteria and strong nursing observation skills. Without a professional nursing assessment the physician may be left in the dark with little else to do but to choose the Broad Spectrum Antibiotic; conversely, a concise nursing assessment could prevent an order for a treatment that may not be in the best interest of the patient.  

“Observation tells how the patient is; reflection tells what is to be done; training tells how it is to be done.Training and experience are, of course, necessary to teach us too; how to observe, what to observe; how to think, what to think.” (Nightingale, 1882)

Reference picture: CDC Phil (March 23, 2012) http://phil.cdc.gov