IC in Care Series: Long-Term Care

By Kelly M. Pyrek

Editor's note: This article was part of a series published in the print issue of ICT in 2016 and may not reflect the most current CMS developments.

With the U.S. healthcare reform mandate for increasing transparency and improved quality, the need for infection prevention and control in long-term care facilities (LTCFs) is becoming more critical than ever before for the more than 3 million Americans receiving geriatric care in U.S. annually. Consider these facts regarding infection in long-term care:
• An estimated 1.6 million to 3.8 million infections occur in long-term care facilities each year.
• More than 1.5 million people live in 16,000 nursing homes in the United States. Estimates suggest infections could result in as many as 380,000 deaths among those residents each year. 
• The nursing home population is expected to increase to about 5.3 million people by 2030.

Quality improvement efforts in long-term care may get a big boost if a proposed rule is finalized. A proposal announced last July at the 2015 White House Conference on Aging would make major changes to improve the care and safety of the nearly 1.5 million residents in the more than 15,000 long-term care facilities or nursing homes that participate in the Medicare and Medicaid programs. If finalized, unnecessary hospital readmissions and infections would be reduced, quality of care increased, and safety measures strengthened for the more than 1 million residents in these facilities. Many of the proposals build on improvements that nursing homes have already made since 1991, the last time these conditions of participation were comprehensively updated. This rule would bring these best practices for resident care to all facilities that participate in Medicare or Medicaid and implement a number of important safeguards that have been identified by patient advocates and other stakeholders, and include additional protections required by the Affordable Care Act. The proposed revisions by the Centers for Medicare & Medicaid Services (CMS) were published in proposed rule CMS-3260-P, in the July 16, 2015 Federal Register.

Changes include updating the nursing home’s infection prevention and control program, including requiring an infection prevention and control officer, and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. As the Federal Register proposed rule notes in the section Infection Control (§ 483.80): "We propose to require facilities to have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under an arrangement based upon its facility and resident assessments that is reviewed and updated annually." The proposed rule adds, "We propose to require facilities to designate an IPCO for whom the IPCP is their major responsibility and who would serve as a member of the facility's quality assessment and assurance (QAA) committee." In a new section in the proposed rule, Training Requirements (§ 483.95), it states: "We propose to add a new section that sets forth all the requirements of an effective training program that facilities must develop, implement and maintain for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. We propose to require facilities to include mandatory training as a part of their QAPI and infection prevention and control programs that educate staff on the written standards, policies, and procedures for each program." In addition, the proposed rule seeks a competency requirement for determining sufficient nursing staff based on a facility assessment, which includes but is not limited to the number of residents, resident acuity, range of diagnoses, and the content of care plans.

In the proposed rule, CMS alludes to the Department of Health and Human Services (HHS) efforts to reduce the incidence of healthcare-associated infections (HAIs) across providers and its National Action Plan to Prevent HAIs -- the initiative that seeks to coordinate and maximize the efficiency of prevention efforts across the federal government. As CMS explains in the proposed rule, "Given the growing number of individuals receiving care in LTC settings and the presence of more complex medical care, these individuals are at an increased risk for HAIs. There-fore, to advance these initiatives, we have proposed revisions that we believe will provide more opportunities to achieve broad based improvement and contribute to reduced healthcare costs. We also believe this approach would be flexible enough to be adapted to any business model and would allow for targeted interventions specific to the facility."

According to the proposed rule, the total cost to comply with the infection control-related requirements would be $283,944,336 for the first year and the identical amount for year two and thereafter. CMS says the total projected cost of this rule would be $729,495,614 in the first year. This results in an estimated first-year cost of approximately $46,491 per facility and a subsequent-year cost of $40,685 per facility on 15,691 LTC facilities.

The focus on long-term care comes at a time when studies are showing an uptick in nursing home infection rates. A recent study from Columbia University School of Nursing suggested that more must be done to protect residents of these facilities from preventable complications. The study, which examined infections in U.S. nursing homes over a five-year period, found increased infection rates for pneumonia, urinary tract infections (UTIs), viral hepatitis, septicemia, wound infections and multiple drug-resistant organisms (MDROs).

“Infections are a leading cause of deaths and complications for nursing home residents, and with the exception of tuberculosis we found a significant increase in infection rates across the board,” says lead study author Carolyn Herzig, MS, project director of the Prevention of Nosocomial Infections & Cost Effectiveness in Nursing Homes (PNICE-NH) study at Columbia Nursing. “Unless we can improve infection prevention and control in nursing homes, this problem is only going to get worse as the baby boomers age and people are able to live longer with increasingly complex, chronic diseases.”

Herzig and a team of researchers from Columbia Nursing and RAND Corporation analyzed infection prevalence from 2006 to 2010, using da-ta that nursing homes submitted to CMS. While UTIs and pneumonia were the most common, infection prevalence increased the most – 48 percent – for viral hepatitis. Herzig presented findings from the study at IDWeek 2014 in Philadelphia. More research is needed to determine the exact causes behind the increases in infection prevalence, Herzig says. But there are several relatively simple interventions that have been proven to help reduce the risk of infection – and that families should look for when selecting a nursing home for a loved one.

UTIs, far and away the most common infection in nursing homes, increased in prevalence by 1 percent, the study found. UTIs can be pre-vented by reducing the use of urinary catheters and increasing the frequency of assisted trips to the toilet or diaper changes for residents who are unable to use the bathroom. Families evaluating which nursing home to choose for a loved one should ask what protocols are in place to decrease catheter use, and they should also ask how the staff cares for residents with diapers, Herzig says. “Nobody wants to think about diapers, but even if your loved one enters the nursing home able to use the bathroom independently, they may need assistance down the line. Seeing how well toileting needs are met is one way to assess infection risk," she says.

Pneumonia climbed in prevalence by 11 percent, the study found. For pneumonia, and other infections that can spread through the air or contact with contaminated surfaces, proper hand hygiene is essential for prevention. Residents, visitors, and staff should all have easy access to sanitizer or soap and water to clean their hands and be encouraged to do this frequently. “When you walk into a nursing home for the first time, you should easily spot hand sanitizer dispensers or handwashing stations,” Herzig says. “If you don’t see this, it’s an indication that infection control and prevention may be lacking at the facility.”

MDRO infection prevalence increased 18 percent, the study found. Screening for MDROs is an important tool for reducing the risk of MDROs, Herzig says. Families should ask whether residents are routinely screened for bacteria such as C. difficile and methicillin-resistant Staphylococcus aureus (MRSA). While some nursing homes may only screen residents who are symptomatic or at high risk for infection, routine screening of all residents upon admission is likely to be more effective, Herzig says. In addition, it’s worth asking whether a nursing home has private rooms to allow for isolation if necessary and whether families are consulted when their loved one shares a room with a resident who has an infection. “Isolation is a common way to contain MRSA and other infections in hospitals, but in nursing homes this isn’t as common because these facilities are tailored to residential needs. If the nursing home does have rooms for isolation, it suggests a more robust approach to infection prevention and control.”

Research also indicates that long-term care facilities require extra attention to healthcare personnel's use of barrier precautions and person-al protective equipment (PPE).  Healthcare workers frequently contaminate their gloves and gowns during everyday care of nursing home residents with methicillin-resistant Staphylococcus aureus (MRSA), according to a recent study published in Infection Control & Hospital Epidemiology. Mary-Claire Roghmann, MD, lead author of the study, says that 1 in 4 nursing home residents harbor MRSA in some settings. "We know that healthcare workers serve as a vector for MRSA transmission from one resident to another in settings such as nursing homes,” she says. “The use of barrier precautions, such as gowns and gloves, limit this transmission, but guidance on when to use them is limited. The goal of our research was to determine the most important times to wear gowns and gloves in nursing homes by measuring the risk of MRSA contamination during different types of care.”

Roghmann and her colleagues conducted a prospective observational study at 13 community-based nursing homes in Maryland and Michigan, evaluating 403 residents for MRSA colonization and then assessing whether interactions with healthcare workers lead to contamination of their gowns and gloves by MRSA bacteria. The study found 28 percent of residents (113 out of 403) harbored MRSA. Glove contamination was higher than gown contamination (24 percent vs. 14 percent) reinforcing the importance of hand hygiene between residents to prevent trans-mission of MRSA. High-risk activities linked to glove or gown contamination included dressing residents, transferring residents, providing hygiene such as brushing teeth or combing hair, and changing linens and diapers. Healthcare workers do not wear gowns during much of this care be-cause they don’t anticipate that their clothing will come into contact with body secretions during this care.

“This research is particularly important since residents in these communities require a lot of assistance from their healthcare workers," Roghmann says. "New MRSA acquisition in nursing homes is substantial. Our study, for the first time, defines the type of care that increases the risk of transmission and suggests modifications to the current indications of gown and glove use."

Another key issue in the long-term care facility is awareness of the back-and-forth flow of nursing home residents to hospitals and back to the LTCFs again. As CMS notes in its proposed rule for LTCFs, "The transfer to an acute-care hospital is a stressful event for a resident of a SNF or NF. As noted by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in its June 2011 report on Hospitalizations of Nursing Home Residents, such hospitalizations impose a high personal cost on nursing home residents, causing disruption, risk of complications and infections, and likelihood of reduced functioning on return to the nursing home (Ouslander and Lamb, et al., 2010). Nursing home residents are especially vulnerable to the risks that accompany hospitalizations and transitions of care, including medication errors and hospital-acquired infections. Preventing potentially avoidable hospitalizations of nursing home residents is an important quality-improvement initiative from the standpoint of the residents and their families, and also may yield cost reductions (Polniaszek and Walsh, et al, 2011)."

The CDC (2015) is urging collaboration between healthcare institutions in terms of patient transfers, as infections and antibiotic use in one facility affect other facilities. The CDC says public health leadership is critical so that facilities are alerted to data about resistant infections, C. difficile, or outbreaks in the area, and can target effective prevention strategies. When facilities are alerted to increased threat levels, they can improve antibiotic use and infection control actions so that patients are better protected.

An August 2015 Vital Signs report from the CDC described the three ways that facilities work together to protect patients
- Common Approach: Patients can be transferred back and forth from facilities for treatment without all the communication and necessary infection control actions in place.
- Independent Efforts: Some facilities work independently to enhance infection control but are not often alerted to antibiotic-resistant bacteria coming from other facilities or outbreaks in the area. Lack of shared information from other facilities means that necessary infection control actions are not always taken and germs are spread to other patients.
- Coordinated Approach: Public health departments track and alert health care facilities to antibiotic-resistant bacteria coming from other facilities and outbreaks in the area. Facilities and public health authorities share information and implement shared infection control actions to stop spread of germs from facility to facility.

According to the CDC, five years after a serious pathogen such as carbapenem-resistant Enterobacteriaceae (CRE) enters 10 healthcare facilities in an area sharing patients:
- With the Common Approach (status quo), CRE will impact 12 percent of patients; 2,000 patients will get CRE
- With Independent Efforts, CRE will impact 8 percent of patients; 1,500 patients will get CRE
- With Coordinated Approach, CRE will impact 2 percent of patients; 400 patients will get CRE
Great care is needed in surveillance efforts. A study conducted by investigators at Rhode Island Hospital and the Miriam Hospital found that a small percentage of nursing home patients carrying multidrug-resistant bacteria are admitted to hospitals without showing symptoms caused by the bacteria. The research, published in the American Journal of Infection Control, highlights the importance of hospital and nursing home infection control practices.

"When patients with drug-resistant bacteria are admitted to hospitals, there is a potential for spread to others," says Leonard Mermel, DO, ScM, medical director of the epidemiology and infection control department at Rhode Island Hospital and author of the study. "A better under-standing of how such bacteria is transmitted between hospitals and nursing homes will enable us to develop control strategies."

Mermel and colleagues documented patients admitted to Rhode Island Hospital and The Miriam Hospital from area nursing homes in 2012. They screened these patients for the presence of CRE since there is little data in the medical literature regarding how prevalent these drug-resistant bacteria are among asymptomatic nursing home patients at the time of admission to hospitals. The researchers identified highly resistant bacteria in 23 of the 500 acute-care hospital admissions from the nursing homes, seven of these were carbapenem-resistant Enterobacteriaceae. They found that the use of a feeding tube was associated with gastrointestinal carriage of these bacteria.

"Such information is helpful in better understanding transmission of such resistant bacteria between nursing homes and hospitals, helpful to focus efforts to reduce antibiotic pressure in nursing home settings, and to better assess the risks and benefits of feeding tubes in this patient population," says Steven Kassakian, MD, a study co-investigator and a post-doctoral fellow in clinical informatics at Oregon Health and Science University.

Cheston Cunha, MD, one of the study's co-investigators and director of the antibiotic stewardship program at Rhode Island Hospital and the Miriam Hospital, adds, "Antibiotic resistance has been called one of the world's most pressing public health problems. When antibiotics fail, infections often last longer, cause more severe illness, require more doctor visits or extended hospital stays, and involve more expensive and toxic medications. Some resistant infections can even cause death. Because therapeutic options are few if infections occur with antibiotic resistant bacteria, antibiotic stewardship and infection control measures are necessary in limiting the spread of these organisms in healthcare settings."

One of the pathogens most likely to be encountered in the LTC environment is norovirus, the most common cause of acute gastroenteritis (AGE) causing both sporadic and outbreak-associated illness. Norovirus (NoV) infections occur across all ages but certain sub-groups are considered at increased risk due to heightened transmission and/or symptom severity. Older adults are potentially at high risk of NoV-associated illness due to frequent outbreaks in LTCFs and severe health outcomes following infection.

Lindsay et al. (2015) conducted a systematic literature review to summarize the published risk estimates of NoV-associated illness, hospitalization and death among individuals aged 65 years and older. A structured search using defined NoV and gastroenteritis (GE) terms was performed in the PubMed and EMBASE databases of human studies published between Jan. 1, 2003 and May 16, 2013. The researchers identified 39 studies from high income (HI) and upper-middle income (UMI) countries. Thirty-six percent of publications provided risk estimates based on laboratory-confirmed or epidemiologically-linked population-based surveillance data using molecular diagnostic methods. Over the study period, estimated annual NoV rates and extrapolated number of cases among older adults in HI and UMI countries were: 29-120/10,000 or 1.2–4.8 million NoV-associated illnesses; 18–54/10,000 or 723,000–2.2 million NoV-associated outpatient visits; 1–19/10,000 or 40,00–763,000 NoV-associated inpatient visits; 0.04–0.32/10,000 or 2000–13,000 NoV-associated deaths.

NoV was responsible for approximately 10 percent to 20 percent of GE hospitalizations and 10 percent to 15 percent of all-cause GE deaths among older adults. Older adults experienced a heightened risk of nosocomial infections. Those in LTCFs experience frequent NoV outbreaks and the range in attack rates was 3 percent to 45 percent, case hospitalization rates 0.5 percent to 6 percent, and case fatality rates 0.3 per-cent to 1.6 percent.

The researchers concluded that older adults are at increased risk of severe NoV-associated health outcomes. NoV-associated hospitalization rates were higher, more severe, resulted in longer stays and incurred greater costs than for younger patients. NoV-associated mortality rates were approximately 200 percent higher among individuals 65 years and older compared to <5 years. The researchers say that the burden of NoV among older adults is expected to rise along with societal aging and increased need for institutionalized care, and that NoV prevention in older adults, including potential vaccination, may significantly impact risk of severe illness.

Influenza is a serious health threat, especially for vulnerable populations like older adults and people living with long-term chronic medical conditions, like asthma, diabetes, heart disease, and kidney and liver disorders. So, it’s especially important that all people living with or caring for those with chronic medical conditions and/or aging persons –  including those working in LTC facilities – get vaccinated against the flu and other vaccine-preventable diseases. Healthcare personnel in LTC facilities may have direct or indirect contact with older adults, persons with disabilities, and persons with chronic medical conditions receiving care. Studies have attributed influenza outbreaks in LTC facilities and hospitals to low influenza vaccination coverage among healthcare workers in those facilities. During a confirmed flu outbreak in an LTCF, up to 1 in 3 residents and one in four staff develop flu-like illness. Preventing flu among healthcare personnel can help reduce the spread of flu in vulnerable LTC resident populations.

The best way to prevent the flu is by getting a flu vaccine each year. Healthcare personnel should get their flu vaccinations by October if possible (or soon after the flu vaccine becomes available). Since it takes about two weeks for antibodies to develop after being vaccinated, make sure your staff are vaccinated early in the flu season so that they are protected before flu becomes prevalent in the community and in LTC facilities. Continued efforts are needed to ensure HCP are vaccinated early in the flu season. Vaccination coverage among certain healthcare personnel, especially those in LTCFs, and among assistants and aides and administrative and non-clinical support staff in all work set-tings needs the most improvement. There are a number of studies that show proven interventions to promote flu vaccination among healthcare personnel each season. Some strategies that employers should use to reduce barriers to healthcare personnel vaccination include offering flu vaccination onsite over multiple days and shifts, free of charge, and with frequent and strong promotion. To help LTC employers increase flu vaccination among healthcare personnel in LTC settings, the National Vaccine Program Office and CDC launched a Toolkit for Long-Term Care Employers. This comprehensive toolkit includes a number of resources intended to help long-term care facility, agency, or corporation owners and administrators provide access to flu vaccination for their workforce and to help LTC employers understand the importance of flu vaccination for their employees.

As we have seen, patient transfer can facilitate pathogen transmission. New recommendations from the CDC last September advise all nursing homes to improve antibiotic prescribing practices and reduce their inappropriate use to protect residents from the consequences of antibiotic-resistant infections, such as C. difficile. To guide these improvements, CDC has released a new resource: Core Elements of Antibiotic Stewardship for Nursing Homes. The Core Elements for Nursing Homes expand upon CDC’s recommendation last year that all acute-care hospitals implement an antibiotic stewardship program designed to optimize treatment of infections while reducing adverse events associated with antibiotic use.

Approximately 4.1 million Americans are admitted to or reside in nursing homes each year.  Antibiotics are the most frequently prescribed medications in nursing homes. Up to 70 percent of residents receive one or more courses of antibiotics during a year. Up to 75 percent of antibiotics prescribed in nursing homes are given incorrectly, meaning either the drug is unnecessary or the prescription is for the wrong drug, dose, or duration. The Core Elements provide practical ways for nursing homes to initiate or expand antibiotic stewardship activities. The guide provides examples of how antibiotic use can be monitored and improved by nursing home leadership and staff. The companion checklist can be used to assess policies and practices already in place and to review progress in expanding stewardship activities on a regular basis. However, depending on resources, some facilities may need more time to implement all these important protections. Ultimately, nursing home antibiotic stewardship activities should, at a minimum, include the following:
1. Leadership commitment: Demonstrate support and commitment to safe and appropriate antibiotic use.
2. Accountability: Identify leaders who are responsible for promoting and overseeing antibiotic stewardship activities at the nursing home.
3. Drug expertise: Establish access to experts with experience or training in improving antibiotic use.
4. Action: Take at least one new action to improve the way antibiotics are used in the facility.
5. Tracking: Measure how antibiotics are used and the complications (e.g., C. difficile infections) from antibiotics in the facility.
6. Reporting: Share information with healthcare providers and staff about how antibiotics are used in the facility.
7. Education: Provide resources to healthcare providers, nursing staff, residents and families to learn about antibiotic resistance and opportunities for improving antibiotic use.

“We encourage nursing homes to work in a step-wise manner implementing one or two activities at first, then gradually adding new strategies from each core element over time,” says Nimalie Stone, MD, a CDC medical epidemiologist for long-term care. “Taking any of these actions to improve antibiotic use in a nursing home will help protect against antibiotic-resistant infections and more effectively treat infections. This could lead to better recoveries from infections and ultimately improve health outcomes for all residents.”

As we have seen, CMS proposed a rule that would require long-term care facilities to incorporate an antibiotic stewardship program, including antibiotic use protocols and antibiotic monitoring, into their infection prevention and control program. According to CMS, these requirements will decrease unnecessary or inappropriate antibiotic use by ensuring that residents who need antibiotics are prescribed the right drug at the right dose for the right duration.

“Nursing homes that engage in antibiotic stewardship improve care for residents and help reduce antibiotic resistance,” says Patrick Con-way, MD, MSc, CMS deputy administrator for innovation and quality and CMS chief medical officer.

The release of CDC’s Core Elements for Nursing Homes is one step in achieving the objectives set out in the National Action Plan for Combating Antibiotic-resistant Bacteria. Investments to improve antibiotic stewardship across all settings are part of CDC’s Antibiotic Resistance Solutions Initiative for fiscal year 2016. As part of the plan, within three years CDC will provide technical assistance to federal facilities (e.g., those operated by the Department of Defense, the Department of Veterans Affairs, and the Indian Health Service) and other large health systems to scale up implementation and assess interventions to improve outpatient antibiotic prescribing, extend effective interventions to long-term care set-tings, and ensure long-term sustainability of antibiotic stewardship efforts.

Resources and Tools
In 2014, the Centers for Disease Control and Prevention (CDC) launched a new website with infection prevention resources for long-term care settings such as nursing homes and assisted living. This site organizes existing infection prevention guidance and resources into sections for clinical staff, infection prevention coordinators, and residents. Facilities can also directly access the new infection tracking system for long-term care facilities in CDC’s National Healthcare Safety Network, and the innovative infection prevention tools and resources developed as part of the partnership between CDC and the Advancing Excellence in America’s Nursing Homes Campaign (AE).

Also in 2014, the Joint Commission released an online educational tool designed to apply the principles of high reliability to reducing infections in long-term care settings.  The learning module, “Applying High Reliability Principles to the Prevention and Control of Infections in Long Term Care,” was partially funded through a conference grant from the Agency for Healthcare Research and Quality (AHRQ). It is a 50-minute, easy-to-use and engaging e-learning tool that can be viewed all at once or in two parts, depending on the needs of the audience. It is free to anyone, not just Joint Commission customers, in online or CD formats. The goal of the module is to introduce the principles of high reliability and show how they can have a significant impact on infection in long-term care settings.

High-reliability solutions come from the study of industries such as commercial aviation and nuclear power that operate under hazardous conditions while maintaining exemplary safety records. Adapting and applying the lessons from these industries offers the promise of enabling healthcare organizations to reach levels of quality and safety that are comparable to those of the best high reliability organizations.

The learning module demonstrates these principles and directly connects them to typical situations in long-term care. It includes examples, quizzes, discussion questions and other resources so participants can ensure they are getting the maximum benefit from the module. It is best used by viewing in small groups and then discussing how the lessons learned apply to a particular care setting.

“Infections jeopardize patient safety. They cause pain, suffering and can even lead to death. Financially, infections can lead to unnecessary expenses for residents and families and higher costs to organizations as well as third-party payers,” says Ana Pujols McKee, MD, executive vice president and chief medical officer of the Joint Commission. “The bottom line is that residents, their families and staff expect care to be safe. This new education module can help long-term care organizations in their journey to achieve zero harm.”

“Healthcare-associated infections are a critical problem facing the healthcare system,” says James Cleeman, MD, director of AHRQ’s Healthcare-Associated Infections Program. “This important learning module will help staff in long-term care facilities prevent infections and pro-vide the safest care possible for patients.”

The learning module is recommended for all staff levels of a long-term care facility-from the environmental services staff to the administrator -so the principles can be put into place throughout the entire organization. At the completion of the program, participants are expected to have achieved four learning objectives that can result in safer patient care:
• Know the characteristics of high reliability healthcare.
• Identify how infection prevention and control practices in long-term care can incorporate high reliability principles.
• Summarize how to take a systems approach to preventing errors related to infection prevention and control.
• Apply the concepts of high reliability to the prevention of infection in the individual’s own organization.

In January 2014, the Association for Professionals in Infection Control and Epidemiology (APIC) published the Infection Preventionist’s Guide to Long-Term Care to assist facilities in creating and implementing comprehensive infection prevention programs. The Guide is accompanied by a CD-ROM with customizable forms, tools and resources. Developed by a team of infection prevention experts, the book presents topic-specific information in a user-friendly format that includes numerous examples, visuals, checklists, and references to help increase the understanding of regulatory requirements, comprehensive infection prevention risk assessment and program development, surveillance and reporting, nursing assessment and interventions to prevent the most commonly occurring infections in long-term care, environmental cleaning and disinfection, unique long-term care issues such as care transitions and life enrichment activities, occupational health, immunization programs, and staff education, as well as disaster and pandemic preparedness.

Compared to an acute-care setting, long-term care can seem like a brave new world. LTC guide co-author Deborah Patterson Burdsall, MSN, RN-BC, CIC, in her chapter addressing Understanding Infection Prevention in Long-Term Care, outlines the realities of infection control in a skilled nursing facility: "Sixty percent of LTCFs are for-profit. A profit-driven structure can produce high-resident/HCP ratios and supply restrictions as a strategy to produce profit and reduce costs. Both high-resident/HCP ratios and supply restrictions result in less time for care, a decreased ability to keep the environment clean, and encourage cutting corners when performing infection prevention activities. Lapses in in-fection prevention activities not only increase the risk of intra-facility transmission, but also are often correlated with citations by the Centers for Medicare & Medicaid Services (CMS) Survey and Certification. If nursing assistants, nursing departments, and infection prevention and control programs are not supported, and if there are insufficient supplies, outbreaks of infectious diseases can be well established before nurses or primary care providers are aware they exist."

For infection preventionists crossing from acute-care into long-term care, there are some principles and practices that are universal, says Steven J. Schweon, RN, MPH, MSN, CIC, HEM, an infection prevention consultant in Saylorsburg, Pa.

"The evidenced-based universal principles and practices of infection prevention are applicable across the life-span and practice setting," Schweon says. "Hand hygiene, aseptic technique, vaccination, environmental hygiene, antibiotic stewardship, surveillance, etc., are very pertinent, promote good outcomes, and can be applied to residents and patients of all ages."

Schweon says that as someone who has transitioned from acute-care to long-term care, there are several key points to continually keep in mind:
- Many of the residents have multiple co-morbidities such as diabetes, functional decline, altered sensorium, failure to thrive, incontinence, and obesity, which may be challenging to control and also increases their infection risk.
- LTC resources, both human capital and equipment, are more limited when compared to acute care. Staff turnover may be higher when compared to acute care.
- The staff and residents will be very receptive to receiving the infection preventionist’s knowledge with reducing infection risk and promoting wellness. The IP may achieve greater job satisfaction as a LTC IP when compared to their acute-care role.
- There is the potential to form very gratifying, long-term relationships, with both the resident and the family, in addition to the employees

IPs going into long-term care must be aware of the characteristics of these residents, as Burdsall points out that, "With an average age of 80 years, older adult residents generally live in LTCFs because of a self-care deficit or a medical condition that requires constant and consistent support. Residents require assistance ranging from cues and reminders to total dependence and are more likely than those who are living independently to have conditions such as: Increased frailty, dementia, decreased immune function, decreased skin integrity and wounds, problems with nutrition, chewing, and swallowing, issues with incontinence, decreased bowel and bladder function, and decreased mobility."
In addition to unique resident characteristics, there are numerous staff-related issues such as lack of healthcare provider education, staff turnover due to working conditions and lower pay, and challenges related to multiple staff from different cultures that either reinforces or challenges prior beliefs, cultural taboos, teachings, and behaviors.

Burdsall advises that IPs, as well as all healthcare personnel working in long-term care, provide a "person-centered approach to maintain health and avoid preventable infection." She adds, "It is estimated that there are between 1.6 and 3.8 million infections annually in elderly residents of LTCFs. The population of individuals over age 85 is expected to grow to 7.3 million by 2020, and a focus on preventable infection is critical since the personal and economic expense of infection is high."

In APIC's LTC guide, Burdsall points to the incidence and prevalence of LTCF infections reported in the literature that can be "skewed by outbreak investigations conducted by public health or investigations external to the LTCF infection prevention program. Also, lack of established surveillance systems in LTCFs which cannot distinguish between new incidence and point or period prevalence." Studies have indicated, however, a reported incidence of between 1.8 and 13.5 infections per 1,000 resident days, and that between 3 percent and 15 percent of 1.43 mil-lion residents in acquire infections in LTCFs annually. Studies also suggest between 350,000 and 400,000 deaths from infections in LTC, with a cost between $673 million to $2 billion.

Outbreaks can occur in long-term care as easily as they can in acute-care. As Burdsall explains in the APIC LTC guide, "Infectious organisms can be difficult to control when introduced into the LTCF population. This introduction may be via a resident admission, a visitor, or HCP. Trans-fer between different levels of community and healthcare treatment facilities increases exposure to foreign microorganisms, and increase the risk of infection with MDROs. When a vulnerable older population comes into close contact with an often under staffed, partially trained, and/or marginally supervised nursing assistant population, it may be difficult to prevent the spread of infectious agents or to control outbreaks with LTCF resources alone. Contaminated HCP hands, gloves, and equipment can spread pathogens between the resident, the environment, and the HCP. Residents with dementia can spread pathogens through contaminated hands, clothing, equipment, uncontained drainage, or uncovered wounds. Outbreaks can be caused by breaks in technique and may have an impact on the HCP health and their ability to work, especially if the HCP acquires the illness. Outbreaks affect organizational economic well-being, regulatory status, and reputation by increasing the need for supplies and reducing admissions, which also increases the possibilities of citations and lawsuits and media exposure."

Studies indicate that the reported prevalence of infections ranges from 1.6 to 32 percent; incidence rates have been reported ranging from 1.8 to 13.5 infections per 1,000 resident days. Burdsall says this wide range of both prevalence percentages and incidence rates "can be attributed to the lack of standardized infection definitions, surveillance, reporting, as well as the general lack of comprehensive infection prevention and control programs. Infections in LTCFs are associated with HCP training and motivation, staffing patterns, HCP wellness, availability of necessary medical supplies, and environmental condition and suitability. They are also affected by the HCP and the organizational views regarding the importance of infection prevention and control. Infections may also be associated with resident level of ADL dependence, dementia, as well as increased contact with peers, HCP, and the environment. Skin condition, invasive devices, dehydration, malnutrition, chronic illness, and immobility affect the rate and susceptibility to infection."

Schweon says there are a few key issues in long-term care that should be in the forefront of IPs' minds:
1. Ensuring there is a robust employee and resident hand hygiene program in place.
"We know that hand hygiene is the most simple, effective way of preventing infection," Schweon says. "It’s key that there’s an adequate amount of alcohol based handrub dispensers, at the point of care, throughout the facility and the staff is performing hand hygiene, per the facility policy. Additionally, having a resident hand hygiene program in place, beyond morning and afternoon care, will help to keep the residents healthy. For example, ensuring all residents are offered the opportunity to perform hand hygiene prior to meals will keep them healthy."
2. Having an antibiotic stewardship program in place will ensure appropriate treatment for infections, improve resident outcomes, reduce multidrug-resistant organism development, limit Clostridium difficile infection, and result in cost savings.
"It’s paramount that the ‘right drug is prescribed for right bug’ and infection, not colonization (e.g., asymptomatic bacteriuria) is treated," Schweon emphasizes.
3. Assuring infection prevention awareness and education is at the forefront for all employees, residents, and visitors.

"For example, it’s key that all employees provide care, in such a way, that does not transmit pathogens to the residents," Schweon says. "We know that LTCF employees can transmit the influenza virus to the residents, thus increasing their morbidity and mortality risk. For me, I would like to see all LTCF employees make a resident safety commitment and receive the influenza vaccine. Unfortunately, this does not occur, and mandatory influenza vaccination is not mandatory, yet, in the LTC setting. Another example is ensuring the environment and resident care items are cleaned and disinfected on a consistent basis. This will reduce microbial bioburden in the environment and reduce pathogen transmission."

Schweon adds that the LTC infection preventionist may wear multiple hats (e.g., assistant director of nursing, clinical educator, etc.) in their facility. "At times, it may be challenging to focus on infection prevention where there are multiple, competing challenges. However, consistently focusing daily on infection prevention will keep the residents, employees, and visitors healthy."

References:

CDC. Vital Signs report: Stop Spread of Antibiotic Resistance. August 2015.

Cunha CB, Kassakian SZ, Chan R, Tenover FC, Ziakas P, Chapin KC, Mermel LA. Screening of nursing home residents for colonization with carbapenem-resistant Enterobacteriaceae admitted to acute care hospitals: Incidence and risk factors. Am J Infect Control. Published online Nov. 26, 2015.

Herzig C. Longitudinal Trends in Infection Rates in US Nursing Homes, 2006-2011.

Lim CJ, Kong DCM, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives. Clin Interven Aging. 2014; 9: 165-177.

 Lindsay L, Wolter J, De Coster I, Van Damme P and Verstraeten T. A decade of norovirus disease risk among older adults in upper-middle and high income countries: a systematic review. BMC Infectious Diseases 2015, 15:425.

Nicolle LE, Bentley D, Garibaldi R, et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol 2000; 21:537–45.

Ouslander JG and Lamb G, et al. Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriat-rics Society, 58, 627-635. 2010.

Polniaszek, Susan, Walsh, Edith G. and Wiener, Joshua M. (2011) Hospitalizations of Nursing Home Residents: Background and Options. U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy.
 
Pyrek KM. Understanding Long-Term Care's Unique Challenges. Infection Control Today. July 13, 2014.

Roghmann MC, Johnson JK, et al. Transmission of MRSA to Healthcare Personnel Gowns and Gloves during Care of Nursing Home Residents. Infection Control & Hospital Epidemiology online. May 26, 2015.