The term Nosocomial Infection has more recently been changed to Health Care Acquired Infection or HAI. 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

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 and also 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

The document can be found under resources on this site. 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

For the next several posts, I will review some of the FAQs I receive from ICPs in Long-term Care.

I have a patient coming in with a history of MRSA in an abdominal wound. Do they need isolation? Do I need a physician’s order for Isolation?

First of all remember to check your Infection Control Manual and your own unique Policies and Procedures. If you don’t have a P & P dealing with this subject you and your DON might want to think about writing one for clarification.

In general: Nurses initiate Standard Precautions on all patients at all times. Standard Precautions include the use of gloves, masks, goggles, and gowns; these items are referred to as PPE (Personal Protective Equipment) and are necessary to prevent the transmission of infectious organisms. We use Standard Precautions on all patients because we don’t always know who has what, for sure. SP protects the patient, other residents and the healthcare worker.

Nurses initiate Transmission Based Precautions for additional protection (Droplet/Contact Precautions) when:

• Blood or body fluids cannot be contained
• Respiratory secretions are not contained/coughing, sneezing and expelling organisms into the air
• Patient is confused, non- compliant or contaminating the environment

When you are unsure about whether to isolate or not, advocating on the side of reducing risk would be prudent until more medical information becomes available; then you can adjust accordingly. Here are some valuable links on the subject:

CDC: Standard Precautions

CDC/ PPE

CDC/HICPAC Isolation Precautions 2007

Los Angeles Department of Public Health MDRO Guidelines

California Department of Public Health Enhanced Standard Precautions 2010

References:

Fardo, R., Keane, J., & Taylor, K. (2009). The APIC Infection Prevention Manual for Long-Term Care Facilities, 2nd Edition. Section V. pg 2. Washington, DC: APIC

1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
2. Photo courtesy of CDC/PHIL http://phil.cdc.gov/phil/home.asp

Copyright © Chris L. Walter 2012

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)

There are always questions about PPD conversions and there have been several posts regarding the subject, two just recently (see February 22 nd  and 16 ^th). Remember to follow the Infection Control Guidelines as outlined by your own State Department of Public Health.

In California, the CDPH (California Department of Public Health) outlines very explicit Guidelines for both Healthcare Workers and Residents in Long-term Care facilities. When a facility has concerns or is unsure of how to proceed in certain situations, they call the TB Control Nurse at the local, County Health Department.

The CDC offers a lot of information on the subject including wall charts, Educational DVD’s on the subject of administering and interpreting the PPD, brochures, handouts and even rulers. I have placed links to all of these resources in previous blogs but will do so again.

CDC: TB Topics Page

CDC: Ordering the CDC Mantoux PPD Skin Test Video  (scroll down ordering sheet to locate video)  

CDC: Diagnosis of Latent TB

CDC: Newer treatment for Latent TB

CDC: TB Fact sheets

CDC: Mantoux Tuberculin Skin Test Wall Chart

CDC: Mantoux test administration and interpretation

Reference: CDC Public Health Image Library (March 23, 2012). http://phil.cdc.gov/phil/details.asp

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?

• When visiting the APIC website you will quickly see the Practice Guidance on the tool bar
•  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.  Be sure to visit and review the Elimination Guidelines APIC Elimination Guidelines

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.  APIC Educational Opportunities

 Reference: APIC website, March 12, 2012, http://www.APIC.org

Question: A patient returning from acute hospital was positive for a MRSA culture of the nares, but they are exhibiting no clinical signs and symptoms such as coughing, sneezing, nasal drainage or any signs of a URI. Do they require isolation?

Answer: First of all, remember to follow your own facility policies and procedures. Know where your Infection Control Manual is located and use it when you have a question or concern. Frequently the answers to most IC questions are right there, in your policies and procedures manual, the very ones the Infection Control Committee signed off on. That means you really are bound to use them until they are modified or changed.

Policies become outdated; the Infection Control Professional, the DON and the Infection Control Committee are responsible for updating their policies as needed. Begin by checking the latest guidelines as recommended by the CDC, your State DHS and APIC Guidelines. Make the information available to your committee and at that time decide if it is time to modify and update the policies based on the latest recommendations.   

Here is a link to the CDC guidelines on the subject. You will probably find a pretty close version of them adopted by your State and County DHS.  According to the CDC

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 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