Infection Control Today - 01/2003: Clinical Update

Resident-to-Resident Abuse and Facility-Acquired Infections:Are They Related?

By Brenda Breivogel, RN, BS, MHSA

Amongmany hazards in nursing homes, one of the most difficult to prevent is abuse --it requires a change in human behavior. Prevention of resident-to-resident abuseis even more difficult to prevent due to the age, past experiences,mental/physical health of the residents; design of the facilities and the impactof chronic illness and infections on the residents' behavior. Caregivers must beaware of the risk factors that lead to abuse to be proactive in the reduction ofabuse. Residents in long-term care are coping with a number of stressors andlosses. Internal factors may be hunger, fatigue, untreated or under-treatedpain, sleep disturbances, depression or unidentified medical problems.Loneliness and fear may also be factors that place a resident at risk. Thesefactors are often compounded by the individual's inability to verbalizeproblems, making the situation even more challenging. Factors external to theresident that contribute or trigger agitation and aggressive behavior may benoise or sensory overload. In addition, the residents must deal with the dailyroutine of institutional life. This article will focus only on the relationshipbetween infections and the incidence of resident-to-resident abuse.

For the last year it was thought that there might be a significantrelationship between episodes of resident-to-resident abuse and the presence ofinfections, particularly urinary tract infections. In this long-term careenvironment the infection control practitioner (ICP) often has many otheradministrative responsibilities, including investigating and reporting all casesof abuse to the state department of health. Attendance at numerous educationalseminars, reading and review of resident medical record increased the level ofinterest regarding the relationship of infection and resident-to-resident abuse.Initially a quick overview of the last six months' resident abuse log andinfection logs was made. There seemed to be a trend identified, so a 12-monthretrospective review was initiated. Utilizing the logs a medical record reviewwas performed. Data were collected to compare the resident age, length of stay,unit location, type of abuse and the presence of infection.

Infection

The presence of infection among facility residents directly contributes tothe residents' irritability and increases the risk of abuse. Incidence rates forfacility-acquired infections in long-term care range from 2.6 to 9.5 per 1,000resident days. Infection rates vary due to the type of facility, the nature ofthe resident population, the definition of infections used and the type ofanalysis done. The reasons for infections in long-term care are the age of theresident, multiple co-morbidities, invasive devices and impaired functionstatus. Signs and symptoms of infection in this population are frequentlyatypical and subtler when compared to other populations. This segment of theelderly population is more susceptible to infection due to underlying diseases,medications that alter resistance to the infection, impaired mental status,incontinence, invasive devices and the rapid transfer of residents fromacute-care hospitals to long-term facilities.

In this environment the most common type of infection is urinary tractinfections (UTIs). The incidence rate for UTIs in long-term care varies slightlyfrom one study to another but typically ranges from 1 to 2.1 per 1,000 residentdays. As much as 1 to 8 percent of residents with this type of infection requiretransfer to the hospital and are the source of 50 percent of the bacteremias.The residents of long-term care facilities are at risk for UTIs due togenitourinary abnormalities, hydration, lack of estrogen for women, changes inprostate function in men and general functional impairment. Some studies suggestthat infection result from a breakdown in local defense mechanisms in thebladder, which allows bacteria to invade the bladder mucosa. As with otherinfections seen in the long-term care population the symptoms of UTIs tend to besomewhat different than those reported in acute care. In many cases the firstsign of a UTI is a change in behavior, confusion or a change in functionalstatus or delirium. Other symptoms which the resident may or may not experienceare: nausea, vomiting, loss of appetite, bladder spasms, dysuria, frequency,urgency, urinary incontinence, itching, feeling of warmth during urination, lowback pain, chills, flank pain, low grade fever and males may have drainage.

The most common organisms isolated from residents with UTIs are: E. coli (50to 60 percent), gram-negative pathogens (30 to 40 percent), or gram-positivebacilli (10 percent). Often the residents cannot clearly express what symptomsare present; because of this it takes a careful assessment by the caregiver tonotice these subtle changes. Yet the only recognized symptom of a UTI may be theabuse of another resident or staff member.

Age related-changes in the respiratory tract increase the risk of infection-- micro aspiration, colonization of the tracheo-bronchial tree, increased chestdiameter and rigidity, muscle weakness, weakened cough, decreased salivaproduction, altered mucus secretion and ciliary action, collapse of lowerairways and decline in alveolar macrophages. The key sign of respiratoryinfection (especially pneumonia) seen in this population is an increasedrespiratory rate. Eighty percent of all recognized pneumonia comes on suddenly.The incidence rate ranges from 0.4 to 4.4 per 1,000 resident days.

Changes in the gastrointestinal system of elderly residents, which make thispopulation more susceptible to infection are: decreased saliva production,slowed esophageal emptying, reduced gastric acid and changes or decreasedintestinal flora. Incident rates for gastrointestinal infections range from 0 to0.9 per 1,000 resident days. Viral gastrointestinal infections are usually mild,self-limiting and abrupt in onset. While bacterial gastrointestinal infectionsare identified by having blood in the stool and have a gradual onset. Most ofthese infections are usually associated with food.

In long-term care, skin and soft tissue infections are most often associatedwith pressure ulcers. Rates seen in long-term care range from 0.1 to 1 per 1,000resident days. Factors related to the age of the residents increase thepossibility of infection. These are: thinning of the skin and support tissue,loss of elasticity and strength, decreased production of sweat and sebaceousglands, lower oxygen levels and peripheral neuropathy.

Abuse

Often abuse between residents occurs because of cognitive impairment, sharedliving arrangements, poor health, functional impairment, internal factorscausing increased stress, social isolation and the history of abuse by others.Often residents who abuse other residents are found to have a history of abusingothers or being abused, insult staff or residents, show demanding or criticalbehaviors, do not want or accept help, undo caregiver's assistance, "getinto things," or are agitated, confused or resists care. Interactions amongresidents maybe considered abusive if the intent of the exchange is toembarrass, intimidate or threaten another person. Several characteristics mayplace a resident at risk to be abused by other residents:

• Behavioral problems (manipulative, repetitive, aggressive, abusive)

• Communication deficits

• Physical impairments

• Cognitive/social impairment.

These may be associated with functional complaints such as sleepdisturbances, reduced appetite and impaired concentration or memory. Medicalillnesses have secondary effects on the resident that take the form of reactivebehaviors, attitude and mood. Emotional and personality changes, disorientation,disorganized thoughts, attention disturbances, sensory changes, altered level ofconsciousness, loss of memory and changes in functional status impact theresident's behavior. The environment also affects the resident's behavior whenthe following exist: complexity, input excess, monotony, irritability,dependency, triggers and background irritants.

Definitions

The definitions utilized to determine whether an infection was present forthe study the definitions found in the APIC Text of Infection Control andEpidemiology. While performing the study the definitions of abuse used areincluded in federal regulations (F tag 223). This is the federal regulation thatstates, "The resident has the right to be free from verbal, sexual,physical and mental abuse, corporal punishment and involuntary seclusion."The guidelines to surveyors include the following definitions:

• Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability.

• Sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault.

• Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment.

• Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

• Involuntary seclusion is defined as a separation of a resident from other residents or his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative.

This regulation requires facilities to investigate, develop a plan forprevention of further episodes of abuse and report the event to the departmentof health. Thus it is important to identify residents at risk of exhibitingproblem behaviors, protect potential victims of abuse and define the causes ofthe behavior so a plan of care can be developed.

The Study

This study included all the residents that initiated the abuse with anotherresident. During the 12-month study period, there were 46 cases ofresident-to-resident abuse reported to the state department of health. The datautilized is from a 209-bed, for-profit nursing home located in the Midwest.Excluded from the study were the cases of resident-to-staff abuse andstaff-to-resident abuse.

The Results

There were 46 cases of abuse during the 12-month study period. Twenty-fourcases involved verbal abuse (52.2 percent); 17 cases of physical abuse (37percent); four cases of combined verbal and physical abuse (8.7 percent); and,one case of mental abuse (2.2 percent). The average age of the abuser was 84.6years and the average length of stay in the facility was 2.4 years. The range onthe length of stay was from one week to nine years. Twelve residents represented30 cases (or 65.2 percent of the cases). Twenty-nine (63 percent) of theresidents initiating the abuse had an infection at the time of the event.Infections associated with the reported cases of abuse include: 20 UTIs (69.4percent), four URIs (13.8 percent) and five other infections (17.2 percent).More specifically, the other infections included one of each of the following:oral, pelvic, vaginal, skin and ear.

Twenty-one (45.7 percent) of the cases came from Unit 3, a Medicaid certifiedunit that has several resident with a length of stay greater than five years.The locked unit for residents with Alzheimer's and other related conditions(Unit 1) had the second highest number of cases reported at 15 (or 332.6percent). Unit 4 came in third with six cases (or 13 percent). Fourth was theskilled unit, Unit 2, with four cases (or 8.7 percent). The units were thenranked on the higher rate per 1,000 resident days: Unit 1 (1.47, Unit 3 (0.99),Unit 4 (0.39) and Unit 2 (0.2).

Discussion

This study does not examine other possible contributing factors such asexcess disability, coexisting illnesses, cognitive deficits or the environment.No resident demographics other than the resident room assignment were utilized(not the location where the abuse occurred). The season when the abuse wasreported was not considered by this study. It would be interesting to explorewhether the resident was being treated for depression and whether the residenthad experienced a decline in activities of daily living or range of motionwithin the last 90 days. In addition, the recent hospitalization of the resident(in the past 30 days) might be explored as a contributing factor.

A future study should be done to examine the coexisting factors to determineif there is a combination of factors that together are predictors ofresident-to-resident abuse. There is a significant association betweeninfections and resident-to-resident abuse, however, just because the residenthas an infection the resident may not become abusive to another resident. Thepresence of an infection in a resident with a history of abusing others shouldtrigger additional precautions to prevent the resident for abusing otherresidents. Infection prevention strategies impact resident-to-resident abuse byeliminating one of the possible contributing factors. Caregivers should besensitive to the subtlest changes in the residents' behavior (especiallyresidents that have a history of abusing others). The earlier an infection isidentified and properly treated the lower the risk of resident-to-resident abuseoccurring.

To prevent episodes of resident-to-resident abuse it is important tounderstand the cause. Prevention strategies can then be developed to focus onthe cause of the behavior. Differentiation of the possible causes maybe done byexploring the social, medical, mental and emotional history; performing aphysical exam; reviewing the resident's medication history; identifyingbehavioral trends and triggers; and identifying activity preferences anddislikes.

Brenda Breivogel, RN, BSN, MHSA, has been a member of the Association forProfessionals in Infection Control and Epidemiology (APIC) for more than 20years and has worked in acute care, critical care, long-term acute care andlong-term care. She currently serves as regional co-director for the APIC-INregion 9.