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; 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







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


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) 

Survey Window

It’s survey time. State surveyors are on the premises asking questions and expecting valid explanations. What may feel like a terminal inquisition to the Infection Control Designee may go something like this:


  • Where is your Infection Control Manual?
  • Do you follow your own Policies and Procedures? Where are they located?
  • Where is your Policy for Scabies?
  • How long does the patient need to be on contact isolation after treatment with Elimite for Scabies?
  • Who needs to be offered treatment for Scabies?
  • Do you have a policy for Outbreak Management? May we see it?
  • Do you have an effective hand hygiene program?
  • We observed the wound care nurse removing her gloves and not washing her hands or using alcohol sanitizer.
  • We observed the Nursing Assistant in the hallway with gloves on.
  • We observed a Dietary Aid taking a tray into the room of a patient on Contact Isolation without using PPE.
  • This patient was re-admitted from the hospital with MRSA of the Nares; why isn’t she on Isolation?

There is a good answer for every one of these queries; some depend on individual facility Policies and Procedures; most answers can be found in the CDPH Infection Control Guidelines for Long-term Care

If you are familiar with your Policies and Procedures, the answers are really not that  difficult; if not, one could become rattled and lose the ability to effectively communicate with the surveyors; what then?

Will you be able to call your consultant in time to find answers to the questions?

Will the consultant be available at the moment you need them?

Would you choose a mad, fearful last minute scramble, or would you rather plan ahead, remain calm and retain those good feelings of being in control?  The reality is the DSD, or whoever is the infection control designee, should know the answers to the questions. Now is the time to really educate ourselves.   

The truth is no one can educate us; they may offer resources and in some cases opportunity for educational experiences, but for the most part, we have to make the effort to find out as much as we can about the specialty we are in charge of, and there is much to learn. It doesn’t have to be overwhelming, to start with, don’t allow yourself to become dependent on someone else; instead, take control of your future and educate yourself.

Start by locating and reading your Infection Control Manual with every opportunity. Find out what your policies are; learn them, understand why you use them, share them and educate others to them. Lastly, insist on compliance.

Most of all don’t wait. Could you answer the questions I mentioned? Don’t depend on a consultant, another nurse, or anyone other than yourself, to find the answers. If you do, it will be too late; you need to be confident enough to answer questions related to the Infection Control Program in your facility. Educate yourself; knowledge brings confidence. Commit to understanding what you do, why you do it, and where the supporting documents for your facility Policies and Procedures are located.

Once you commit to your own education,  your experience will become your expertise and you will be in the position of educating those who are asking all the questions. 

Infection Control Policies & Procedures

Question: What is the purpose of infection control policies and procedures?

Answer: In health care, policies and procedures describe protocols written, reviewed and adopted by the institution one is employed by. They are more than a guide, they define the expectations for performance and set standards that can and will be used to measure the appropriateness of the employee’s behaviors on the job. Whether documents are being created or revised, they must be accurate, consistent, compliant and based on current practice. Outdated policies must be updated at least annually and more often if warranted. 

The policies and procedures that most affect my position are those of the infection control manual. When a facility signs a contract to retain services from a lab and radiology company, they may be provided with an infection control manual that spells out policies and procedures for surveillance, tracking & trending, employee health, environmental issues, education etc.

Once a facility accepts the manual they should review it with their infection control committee; if they wish to adopt the policies and procedures, they must review, adopt, sign the Infection Control Committee Approval page, and rename the manual using the facility’s name. 

More often than not, the manual finds its way to the back of a book shelf  in some obscure office; Staff Developers and Directors of Nursing come and go, no one keeps up with the manual and eventually, many guidelines become outdated. 

Surveyors want to know facilities have an infection control program in place, that they have policies and procedures, and that they follow them. There are times when I receive an urgent call because a surveyor has surprised a facility and is asking questions they cannot answer; why? Because they are not familiar with the infection control manual and therefore, not familiar with their own policies and procedures. These facilities are at risk for being found deficient by surveyors.  


Transmitting Organisms in Long-term Care

There are many organisms to be found in healthcare facilities just as there are in our homes, schools, public buildings and everywhere else in our complex world. We all attract and support organisms who take up residence in colonies, on and about our bodies. Usually, we enjoy a symbiotic relationship with those microscopic entities; they don’t bother us and we can’t see them; would that we could, we’d never stop washing our hands then, would we?

Some of the more highly infectious organisms found in healthcare facilities are the seasonal influenza viruses and noroviruses, which cause gastroenteritis; these viruses are capable of causing outbreaks due to the ease with which they are transmitted from person to person.

All one has to do is stop and think about where their hands have been today, where everyone else’s hands have been today, and what those hands have touched and will touch. Take a minute, close your eyes, and think about it. The possibilities for transmission seem endless, don’t they?

Now, think about interrupting that cycle; think about the barriers you will need to interrupt transmission. It’s really just that simple.

  • Gloves if you anticipate contact with blood or body fluids.
  • Gowns if you anticipate splashes being generated during patient care.
  • Masks if a resident shows signs and symptoms of respiratory illness, i.e. coughing, sneezing.  
  • Goggles, face shields and N-95 respirators are usually not needed in Long-term care situations but should be available.

*As always, Infection Control begins and ends with hand washing (view this visual link) 


The Preventionist

The Preventionist is a weblog for Long-term Care Nurses and Healthcare Workers interested in Infection Prevention and Control. Here you will find timely information, resources  and links to national professional organizations such as the Centers for Disease Control (CDC) the Association for Professionals in Infection Control and Epidemiology (APIC) and Evidence Based Infection Prevention Guidelines.  Hopefully this will be a site you find useful for searching and locating basic information regarding your questions about Infection Prevention in Long-term Care.

Infection Control Resources

I attended nursing school in Southern California, have worked my adult life as an RN in Southern California, became Certified in Infection Control and returned to school for my BSN in Southern California. For these reasons, the  resources I use for my position as an Infection Control Consultant and for my contributions to The Preventionist come mainly from the California Department of Public Health Infection Control Guidelines, the Los Angeles County Department of Public Health, the Centers for Disease Control (CDC) the National Institutes of Health (NIH) and of course the Association for Professionals in Infection Control and Epidemiology (APIC); our national, professional Infection Control Association.

Infection Control Nurses living in other states rely on their individual State and County Infection Control Guidelines to be compliant. Here are some Infection Control links you may find useful in California and nationally as well:    

APIC Guidelines and Standards 

California Department of Public Health Infection Control Guidelines 

California Department of Public Health Enhanced Standard Precautions  

Centers for Disease Control and Prevention

L.A. County Department of Public Health Guidelines for MDRO’s in LTC 

National Institutes of Health


What’s That on Your Hands?

Bacteria are everywhere; they co-exist with us, occupying their own intrinsic colonies on our skin, nasal passages, mouths, well you get the picture. Many bacteria are vital to our good health, while other would-be intruders are capable of declaring war with our immune systems, depending on their virulence (relative strength) and our own current state of health. If we could see the bacteria that have colonized our bodies with the naked eye, it is safe to say we’d be washing our hands more often. 

Try to remember everything your hands touch every day. Then allow yourself the visual image of everyone else touching the same surfaces, people, places and things. If we don’t wash our hands, we transfer all of that to others, to ourselves and to our families as well. Not washing our hands, besides being inconsiderate, is potentially dangerous in a healthcare delivery setting. 

We use barriers such as gloves, gowns and masks and we place patients in isolation, but first, we should make a habit of diluting organisms on a consistent basis. The more we dilute potential pathogens, the less chance there is of transmitting bacteria viruses, fungi and fomites to ourselves and others. When we consistently wash our hands, we dilute the organisms. When we vaccinate ourselves, co-workers, residents, families and the community, we dilute the virulence of disease by preventing it all together. Regularly cleaning the immediate environment creates further dilution. 

Healthcare workers need to wash their hand or use hand sanitizers before:

  • Each patient contact
  • After each patient contact
  • Donning gloves
  • Passing medication
  • Performing treatments
  • Serving food
  • Assisting with drinking or eating
  • After using the rest room.

Well, we all know the drill. But are we compliant? Hand washing is the most important step we can take in reducing and diluting the number of pathogens our patients, families and co-workers are exposed to on a daily basis. Their lives are in our handsIt’s just that simple.