Developing an Effective Infection-Control Policy

by Duncan S. MacLean, MD, CMD

Scenario 1: "Doctor, the Health Department notified us that an elderly Central American resident in our facility has a daughter who just tested positive for TB. The daughter has been coughing noticeably during her weekly visits to her mother these last few months. What should we do?"

Scenario 2: The Infection Control Nurse reported to the Infection Control Committee that the rate of urinary tract infections (UTIs) on a skilled unit had risen during the previous quarter to more than 2.0 per 1000 resident-days, double the published benchmark of 1.2 per 1000. Three of the UTI cases grew the same organism with identical resistance patterns. In addition, on the same unit in the same quarter, there were two new methicillin-resistant Staphylococcus aureus (MRSA) infections--one conjunctivitis and one PEG stoma cellulitis--in the same hall as another resident with a chronic MRSA-infected pressure ulcer. These data were suggestive of nosocomial factors for both the UTIs and MRSAs on this unit.

Scenario 3: "Seven residents and 21 staff developed diarrhea this week. They are all on the same unit. We've had no cases on any other unit. We transferred one resident with diarrhea to the hospital for intravenous fluids and diabetic monitoring, but the rest of the cases are maintaining hydration well. Should we be doing anything else, doctor?"

These are real-life scenarios that I have encountered in several facilities over the last few years (see box, below right, for the follow-up actions and results). Fortunately, these kinds of infectious exposures and outbreaks do not occur frequently. But when they do occur, medical directors need to be prepared to address them aggressively.

These three cases illustrate the vulnerability of frail institutionalized patients to infection. The average nursing home resident contracts one to two infections per year, and infections are the most common reason for hospital transfer (J Am Geriatr Soc 1996;44:74-82). Infections are also among the most significant final causes of death among nursing home residents.

What are the regulatory requirements for infection control? How do these compare with other industry standards, including those of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Association of Practitioners of Infection Control (APIC)? How should policies be structured? What is the medical director's role? This column addresses these questions.

Regulations, Guidelines, & Standards

Tags F441 to F445 cover the infection control (IC) requirements in the 1987 Omnibus Budget Reconciliation Act (OBRA '87) regulations. They require an IC program, but do not specify either a committee or an infection control practitioner (ICP). These regulations address only six issues: case investigation, records, isolation, sick employees, handwashing, and linen handling.

The guidelines that accompany the regulations in the State Operations Manual outline a more comprehensive IC program. These guidelines correspond closely to the APIC recommendations for IC in long-term care (see Resources).

Nebraska State Epidemiologist Phillip W. Smith, MD, authored the APIC recommendations in 1991 and updated them in 1997. They differ from hospital standards for IC because nursing facilities have different patient characteristics, nurse staffing ratios, availability of diagnostics, treatment goals, and payment systems than hospitals.

A prospective study by Haley RW, et al. validated hospital IC standards (Am J Epidemiol 1985;121:182-205). However, APIC's nursing home recommendations have not been similarly validated. Rather, they are based on IC logic, currently available nursing-home-specific evidence, field experience, and expert opinion. The 1997 recommendations have received the endorsement of the Society of Healthcare Epidemiologists in America (SHEA) as well as APIC.

JCAHO's Standards for Long-Term Care IC requirements are similar to those of APIC, though not as detailed. Neither JCAHO nor APIC require a committee, but unlike the OBRA regulations, both specify an identifiable and accountable oversight structure. For instance, the IC program can be a subcommittee of the quality-assurance committee. APIC suggests at minimum a core IC group consisting of the medical director, nursing director, and administrator. In addition, APIC recommends--and JCAHO requires--a program coordinator who, ideally, is a trained ICP.

As employers of health care workers, nursing homes must also adhere to Occupational Safety and Health Administration (OSHA) requirements. These pertain to worker exposure to tuberculosis (TB) as well as to bloodborne pathogens, including human immunodeficiency virus and hepatitis B virus.

Facilities should check additional state and local IC requirements, as well.

Infection Control Policies

APIC recommends written IC policies and procedures, and JCAHO requires them. The OBRA regulations explicitly require a policy only on handwashing, but imply the need for systematic policies for full compliance.

Levenson's Clinical and Administrative Policies for the Medical Director & Attending Physicians (see Resources) includes 13 medical policies on IC. However, his earlier text recommends that facility IC policies and procedures be separate from the medical policies. I recommend the latter approach, with only a single general medical policy establishing physicians' duty to follow facility policies. Heaton Publications offers a model infection control policy manual for nursing facilities (see Resources).

Other recommendations by APIC include policies on:

Surveillance The ICP should collect infection data from weekly walking rounds and from other sources such as the chart, laboratory results, antibiotic records, and hospital transfer information.

The facility should use standard definitions to allow comparison with published benchmarks. The most widely used definitions for infections in long-term care are those of a Canadian consensus conference (Am J Infect Control 1991;19:1-7).

Incidence rates per 1000 resident-days should be calculated monthly. Updated benchmarks (endemic rates) cited by Smith in the 1997 APIC guidelines for total infections are 2.6 to 7.1 infections per 1000 resident-days. Published rates for urinary tract infections in long-term care are 1.2 to 1.5 infections per 1000 resident-days (J Am Geriatr Soc 1994;42:45-49; Am J Infect Control 1999;27:20-26).

Outbreak Control The policy should define an outbreak for each infection. It should define the authority to intervene, including relocating residents, obtaining cultures, restricting visitors, and administering treatments.

Facility Procedures These should include handwashing, housekeeping, laundry, food preparation, and infectious waste disposal policies.

Isolation & Precautions The Centers for Disease Control and Prevention now recommends a simplified two-tier system of Standard Precautions (similar to universal precautions) and Transmission-Based Precautions (Infect Control Hosp Epidemiol 1996;17:53-80).

Asepsis & Handwashing This covers procedures requiring aseptic technique, disinfection of reusable equipment, and choice of handwashing soap.

Resident Care Policies should address accessibility of sinks and toilets; the use of urinary catheters, intravenous catheters, feeding tubes and other devices; maintenance of skin integrity; aspiration precautions; immunizations; and care of HIV-infected residents.

Employee Health These policies deal with baseline employment assessment; PPD testing; blood-borne pathogen exposures; hepatitis B and influenza immunization; avoidance of sick employee contact with residents or their food.

Education Education should be provided upon employment and through periodic in-service training.

Policies & Procedures The facility should maintain an IC policy manual and should update it on a regular basis.

Antibiotic Resistance & Monitoring The ICP should monitor antibiotic susceptibility trends. Facilities should have policies on resistant bacteria such as MRSA and Vancomycin-Resistant Enterococci (VRE). Facilities should consider utilization review of antibiotic appropriateness.

Miscellaneous Other policies should cover reporting to public health officials and oversight by the quality assurance program.

Some facilities are adding procedures dealing with bioterrorism, in the wake of the terrorist attack and anthrax incidents of September 2001.

Role of the Medical Director

The medical director's most important role is to remind the facility of the purpose of the IC program--providing a safe and comfortable environment and preventing the development and spread of infections whenever possible (Ouslander JG, et al. Medical Care in the Nursing Home. New York: McGraw-Hill, 1997). Treatment of infections is not an end in itself, but rather a means to these ends.

The medical director also plays a significant role in:

• Helping design data-collection methods and helping analyze data.
• Analyzing physician practice patterns.
• Developing IC policies and procedures.
• Investigating and helping manage infectious outbreaks.
• Educating staff about infection issues.
• Helping ensure adequate pre-admission screening for infections.
• Participating in the IC process or committee.
• Encouraging prudent use of antibiotics by attending physicians.

Conclusion

A well-structured infection-control program will help prevent infections and manage them when they occur among our highly susceptible residents.

Dr. MacLean is Medical Director of Delaware's state-operated system of nursing homes. He was founding President of the Pennsylvania Medical Directors Association and served as an Issue Expert on Long- Term Care for the 1995 White House Conference on Aging. He has directed a private non-profit nursing home, a hospital-based subacute unit, and a private personal care facility. He has served on AMDA committees, presented at the AMDA Annual Symposium, and conducted Symposium discussion groups.

The opinions expressed by Dr. MacLean are his own and not necessarily those of the American Medical Directors Association.

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