Getting a Handle on Infection Control in Long-Term Care

by Jacqueline Vance, RNC, with Kathleen M. Wilson

Infections continue to be a significant source of morbidity and mortality among residents of long-term care facilities, where more than 1.5 million infections--approximately one to two per resident--occur annually. In fact, despite the best efforts of staff, about one-quarter of hospital admissions from LTC facilities are due to infections, and the incidence of infectious diseases in nursing facilities is on the rise.

Therefore, implementation of appropriate infection-control measures across the continuum of care is more important now than ever before, observed Steven Levenson, MD, CMD, Chair of the American Medical Directors Association's Clinical Practice Committee, and of Caring's Editorial Board (also see Dr. Levenson's Editorial in the September 2001 issue of Caring, p. 3).

Although there has been progress in the long-term care team's understanding of infections and infection-control practice, important questions remain. Despite published studies of estimated prevalence rates for infections in LTC and the availability of specific guidelines for infection-control programs, assessments of the effectiveness of infection-control programs and preventive strategies are limited.

Nevertheless, the Omnibus Budget Reconciliation Act of 1987 requires that all skilled nursing facilities have an infection-control program. The Centers for Medicare and Medicaid Services (CMS, formerly HCFA) implements this federal law by publishing requirements for LTC facilities that accept Medicare or Medicaid patients. Surveyor guidelines address infection control and include definitions of infection, risk assessment, outbreak control, antibiotic monitoring, and assessment of compliance with policies and procedures.

Therefore, it makes sense for facilities to have the best possible infection-control program in place, given their staff and resources. This Special Report and the accompanying CPGs in Action (see the September 2001 issue of Caring, p. 27) provide an overview of the basics and the rationale for implementing a rigorous program.

Key Program Components

A facility's infection-control program should have processes and policies in place for (at the least) surveillance, disease reporting and monitoring, standard and contact precautions, isolation procedures, outbreak control, immunizations, and resident and employee health programs. It should also include systems and processes to recognize, track, and monitor infections along with a systematic approach to preventing them.

An effective program should be interdisciplinary and include the medical director, administrator, and director of nursing--all of whom should be familiar with pertinent federal, state, and local regulations. Secondary team members include employees from the nursing, housekeeping, and dietary departments, and possibly other consultants and a representative from the laboratory that does the facility's cultures. Also, the facility should have someone who coordinates the various infection-control functions as part of his or her job description.

Infection Recognition

Nursing staff should be trained to identify and report conditions that put a resident at higher risk for infection (see box at right). Since older adults do not present with the same signs and symptoms as younger adults, this may create a challenge for some caregivers. For example, clinically infected LTC patients and residents often present with a change in mental status, decline in physical function, or other nonspecific symptom such as increasing confusion, a new episode of incontinence, falling, or a decline in mobility.

Fever also is a sign of a possible infection. Although fever in a younger adult is defined as more than 100 degrees F orally, this may not be true for an older adult. Therefore, it is often useful to establish the criterion for fever in LTC as an increase over the upper limit of an individual's usual daily temperature range.

When infection is suspected, temperature should be taken rectally if possible, since this yields a more accurate result than taking temperature by mouth. If you use electronic thermometers that permit temperature-taking via oral, rectal, axillary, ear canal, and other routes, check with the manufacture to see which route gives the most accurate result.

Tracking & Monitoring

Each unit should have a list of individuals with infections and those who may have early signs and symptoms of infection. The 24-hour report, which is used by the charge nurse on each shift, is an efficient place to record this information.

The pharmacy consultant can help with tracking by running reports on patients and residents who are taking oral, parenteral, or other forms of antibiotics. The reports should be given daily to the infection-control nurse or director of nursing to track on a daily or weekly basis, shared with the medical director, and used to identify trends or possible outbreaks.

Common Infections in LTC

According to data from the Centers for Disease Control and Prevention, the most common infections among LTC residents are urinary tract infections, lower respiratory tract infections, soft tissue infections, and gastroenteritis. Diarrhea secondary to Clostridium difficile toxin is also a concern, as is tuberculosis. In addition, frequent transfers of residents between hospitals and LTC facilities have led to an increase in antibiotic-resistant microorganism infections in LTC facilities.

Urinary Tract Infections

Multiple factors contribute to the high frequency of UTIs in LTC residents, including age-associated physiological changes, comorbid illnesses, poor fluid intake, dehydration, reduced mobility, and the various interventions used to manage incontinence and voiding. For example, condom catheters increase the incidence in UTIs in men with incontinence because the condom and/or drainage tubing tends to twist and kink.

Since the basic physiological causes of UTIs in LTC residents normally cannot be changed, infection-control measures need to concentrate on factors that can be modified. Examples include implementing programs to ensure adequate hydration (to combat low urine volume) in susceptible individuals; developing specific guidelines for the use of indwelling, intermittent, and condom catheters to reduce indiscriminate use; educating the health care team on the use of catheters; and implementing a system to look at medications related to urinary retention.

The program may also include medical director interactions with physicians who may be inappropriately prescribing medications that lead to urinary retention and/or antibiotics for asymptomatic bacteriuria.

Lower Respiratory Tract Infections

Influenza is typically transmitted by facility staff and visitors. Outbreaks are more common when the employee vaccination rate is low, so facilities have a strong stake in getting employees vaccinated.

But getting employees to accept the vaccination, even when offered free as a part of an employee health plan, is difficult. Acceptance rates are low even when incentives and information about vaccine safety are given. Informing staff about the significant mortality rates in the LTC population might help, although an inservice alone is unlikely to lead to changes in behavior (also see "Studies: LTC Staff Still Resist Flu Shots").

Resident vaccination is also a must. To increase the number of vaccinated residents, CMS recommends that facilities use standing orders for annual flu vaccinations and for new admissions during the flu season. Pneumoccocal vaccine also is recommended, and can be given safely with the influenza vaccine, using a different deltoid for each injection.

LTC staff should be aware that residents with influenza may only show reduced appetite, confusi on, and lethargy in addition to a fever (rather than such "classical" symptoms as sudden onset of fever accompanied by pain in the upper back and extremities, headache, chills, and cough), and be on the lookout for these nonspecific symptoms when influenza is reported in the community.

Follow this link to Part 2 of the article.

Jacqueline Vance, RNC, is the American Medical Directors Association's Director of Clinical Affairs and Kathleen M. Wilson is AMDA's Director of Government Affairs. Both are Contributing Writers to Caring. Steven Levenson, MD, CMD, Chair of Caring's Editorial Board, also contributed to this article.

This article originally appeared in Caring for the Ages, September 2001; Vol. 2, No. 9, p. 22-27. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission. The opinions expressed by the authors are their own and not necessarily those of AMDA or of Elsevier.

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