Infection Prevention in LTC: Emphasis Needed on Education, Evidence-Based Practices

By Kelly M. Pyrek

An aging population is swelling the ranks of long-term care (LTC) residents in this country, and the need is greater than ever for the implementation of infection prevention and control in these facilities. Barriers to good practice are numerous for both the frontline healthcare worker and the infection preventionist (IP), but these can be combated with the right skill sets and knowledge, emphasizes Gail Bennett, RN, MSN, CIC, of Rome, Ga.-based ICP Associates, Inc. who has spent many years consulting to LTC facilities and health systems across the country and who was a co-author of the SHEA/APIC guideline on infection prevention and control in the long-term care facility. 

Bennett believes there are several overriding issues that are critical right now for relating to LTC facilities' ability to establish and  maintain knowledge of infection prevention among healthcare professionals in a highly challenging environment.

"Although we see great dedication among long-term care IPs, it is very difficult for the long-term care IP to get comprehensive training," Bennett says. "Sometimes deficient training is due to lack of funding to travel to conferences or to other off-site training programs. In the last few years I have been encouraged because many states are now taking on that issue by providing infection prevention training within the state. I am already seeing some improvement in the companies I have worked with in that more of their people seem to be going to official infection prevention training courses than they have been able to do in the past. There are also some good online training programs, but my concern is that not all IPs in LTC are aware of them. Additionally, some IPs in LTC have good access to computers while others do not. The issue of training IPs is critical to having a solid, comprehensive infection prevention program."

A second confounding factor related to education and training, Bennett says, is chronic staff turnover in LTC settings. "General staff turnover is challenging, but loss of staff members who have been appropriately trained to monitor and run the infection prevention program is even more of a problem," she says. "In the past I have worked with a corporation that owned 12 LTC facilities and for several years I was able to measure their turnover in the infection prevention position and that company had a 68 percent turnover every year.  Despite having a corporate infection prevention consultant, as well as providing full-day, onsite infection prevention training classes three times a year with continuing telephone support, they still had an 68 percent turnover rate during the period of measurement. I don't really know the reasons, but many times these infection preventionists left to perform a different job at a different facility."

Bennett points to published data on overall high employee turnover rates in LTC facilities; 2011 data from the Quality Long Term Care Commission showed the following turnover rates: administrators, 3 percent; director of nursing, 39 percent; RNs, 50 percent; LPNs, 49 percent; and CNAs, 71 percent. "To me, it is alarming that the overall turnover rates are so high."

A report prepared for the National Commission for Quality Long-Term Care by the Institute for the Future of Aging Services (2007) outlined the various short-term trends in long-term care that complicated workforce recruitment and retention, including negative industry stereotyping; low wages and scant benefits; poor working conditions;  and inadequate or misplaced investments in LTC workforce education and training. A significant long-term trend that is exacerbating the situation is the emerging care gap between the number of individuals requiring care and the number of available care providers. Persistent nursing shortages and nursing students'  lack of exposure to the geriatric nursing career path can make it difficult to hire and train appropriately credentialed staff members.  

This revolving door of turnover emphasizes what Bennett calls a "lack of redundancy" in the infection prevention position at LTC facilities. "Many times when the IP leaves employment, there is no one else in the building who has the knowledge needed to run the infection prevention program," she says. "One thing I have been preaching for a long time but I am still not seeing widely, is that every program needs -- at the minimum -- one person trained as back-up for the IP. That individual should have a higher level of general infection prevention knowledge plus training on managing the overall infection prevention program. We must have a back-up because if we are looking at 68 percent turnover in that position, we are losing the knowledge we have been able to procure in that facility."

A third consideration related to staff education and job performance is the LTC infection preventionist's lack of time to devote to her duties, a problem shared equally by acute-care comrades. "The challenge is having enough time to perform the specific infection prevention functions; even if she has the knowledge she has trouble finding the time, and frequently finding more time to allocate to the IP has not been a priority among LTC facility leadership," Bennett says. "We know that the LTC IP is wearing many hats and sometimes the infection prevention portion of her job is quieter than the others in that it does not immediately demand her attention. If she is doing staffing for the building, or doing orientation and training and teaching, and unless she is in an outbreak situation, then infection prevention may be on the back burner."

As with her acute-care counterparts, the LTC IP is charged with not only keeping herself educated, but educating and training frontline care providers who may have considerable knowledge gaps.

"One thing that could be very helpful among all staff is teaching them about the epidemiology of specific organisms and how transmission occurs because there's so much misinformation and sometimes confusion about precautions needed for multi-drug resistant organisms (MDROs)," Bennett says. "So I think knowledge of how certain organisms are transmitted and how we break that chain of infection by use of excellent hand hygiene and other precautions is very important. The second thing looming in infection prevention these days is knowing the importance of the environment and its role in possible infection transmission, and certainly in LTC with C. difficile and norovirus we know the environment can play an important a role. Staff must understand that things are done differently when addressing those two organisms in particular."

Bennett adds that along with C. difficile and norovirus, pathogens such as multidrug-resistant Acinetobacter baumanii and Carbapenem resistant enterobacteriaceae (CRE) are critical issues to address in the LTC environment right now. "The No. 1 consideration is having knowledge of these organisms,  their significance, and if there are important environmental changes that need to be made in that room to assist in preventing transmission. The second intervention is considering careful resident placement. LTC facilities frequently do not have private rooms, so patients residents are may be rooming with someone who may have a serious infection with an MDRO. If private rooms are unavailable, placement with an appropriate roommate that would be considered low risk should be considered. A third intervention is compliance with hand hygiene and with implementation of appropriate precautions, and as we do that, we must also integrate observation in our infection prevention programs. When I teach about infection prevention I always say that "if you don't look, you don't know." We have to ensure good compliance with evidence-based practices as well as our policies and the best way to do that is through observation.  The programs that may be more successful in performing ongoing observation are programs that have infection prevention liaisons who have had additional training in observation and documentation. These liaisons  can be very helpful to the infection preventionist who may not be able to conduct observation herself. The last intervention is to gather good data on those pathogens of concern, and ensure that the data used to identify infections shows that those cases meet the surveillance definitions."

An approach that can have a significant impact on reducing infections in long-term care is implementing targeted strategies according to the organisms that present a problem in the facility, including making smart decisions about the use of transmission-based precautions. In the LTC environment we can't afford to be sloppy. We must have excellent practices, implementing standard precautions as well as transmission-based precautions as warranted, and that is where we make more of a case-by-case decision than is done in acute care. For example we frequently do not implement contact precautions simply because someone is colonized with a resistant organism, but we often do if they have an active infection. In hospitals they tend to put anyone with colonization in contact precautions. But we are working in the resident's home and our decisions always take that into consideration. Fortunately, the CDC isolation guidelines specific to LTC also considered that. Again, as we think about targeted strategies with our precautions, and we must include the component of observation."

As Smith and Bennett, et al. (2008) note, "Barrier precautions are important in preventing cross-infection with known resistant microorganisms, but approaches to isolation of LTCF patients colonized or infected with MDROs vary substantially across facilities. Most LTCFs employ at least some type of isolation for MDROs. It was found that 90.5 percent of facilities accepting patients with MRSA stated that they followed Contact Precautions despite only 39.7 percent placing them in private rooms. In another survey, most LTCFs were aware of and often screened for MRSA and employed some precautions in dealing with these residents (e.g., single room, cohorting, contact isolation, or placing the resident with MDRO in the same room as a low-risk roommate). Another study demonstrated no difference in transmission of MDROs in a skilled care unit between contact isolation precautions and routine glove use. The authors suggested that universal glove use may be preferable to contact isolation because it reduces social isolation for LTCF residents where their healthcare facility is also their home. Others have suggested a 'modified' contact isolation protocol as often more appropriate in the LTCF setting. Clearly, additional evidence-based studies defining the specific isolation needs within LTCF are needed."

HICPAC isolation guidelines attempt to address some of the specific needs and concerns of the LTCF.

According to Smith and Bennett, et al. (2008), the guidelines provide recommendations on the use of transmission-based isolation precautions. In LTCFs, it is advised to consider the individual residents clinical situation when deciding whether to implement or modify the use of Contact Precautions in addition to Standard Precautions if colonized or infected with an MDRO. Standard Precautions are sufficient for relatively healthy and independent residents, ensuring that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool and ostomy tubes/bags. Contact Precautions are indicated for residents with MDROs who are ill and totally dependent upon HCWs for activities of daily living or whose secretions or drainage cannot be contained. Single rooms for these residents are recommended if available. The cohorting of MDRO residents is acceptable if single rooms are not available. If cohorting is not possible, then placing residents with MDRO with residents who are low risk for acquisition or with anticipated short lengths of stay is advised. While low risk for acquisition of an MDRO has not been officially defined, one source suggested that it should include residents who are not immunosuppressed; not on antibiotics; and free of open wounds, drains, and indwelling urinary catheters. Case-by-case decisions, as needed, can be made regarding the best precautions to use for each resident with a MDRO. With Contact Precautions, wearing a gown and gloves for all interactions that may involve contact with the resident and their environment is advised, and eye protection is recommended when there is risk of splash or spray of respiratory or other body fluids."

The healthcare-associated infection (HAI) burden in LTCFs supports the ongoing attention to infection prevention strategies in geriatric settings. The HHS National Action Plan to Prevent HAIs, which was updated this spring, notes, "More recent estimates of the rates of HAIs occurring in NH/SNF residents range widely from 1.4 to 5.2 infections per 1,000 resident-care days. Extrapolations of these rates to the approximately 1.5 million U.S. adults living in NHs/SNFs suggest a range from 765,000 to 2.8 million infections occurring in NHs/SNFs every year. Given the rising number of individuals receiving more complex medical care in NHs/SNFs, these numbers might underestimate the true magnitude of HAIs in this setting. Additionally, morbidity and mortality due to HAIs in LTCFs are substantial. Infections are among the most frequent causes of transfer from LTCFs to acute care hospitals and 30-day hospital readmissions. Data from older studies conservatively estimate that infections in the NH/SNF population could account for more than 150,000 hospitalizations each year and a resultant $673 million in additional healthcare costs. Infections also have been associated with increased mortality in this population. Extrapolation based on estimates from older publications suggests that infections could result in as many as 380,000 deaths among NH/SNF residents every year."

In the updated action plan, the Federal Steering Committees for the Prevention of HAIs LTCFs Working Group decided to focus on the NHs/SNFs settings and five priority areas and goals: National Healthcare Safety Network (NHSN) enrollment, urinary tract infections/catheter-associated urinary tract infections (UTIs/CAUTIs), Clostridium difficile infection (CDI), resident influenza and pneumococcal vaccination, and healthcare personnel influenza vaccination. The committees emphasize that these are "intended not as a final goal but as a first step."

"I am excited about the final HAI Action Plan from the HHS," says Bennett. "I think it will provide more emphasis on the LTC infection prevention program than we have had in the past. The plan, however, is not very aggressive -- HHS has developed priority areas and goals and most of those are giving LTC facilities five years to obtain the goals and that's really too long. The goals are not precipitous and I think there were comments sent to HHS that the goals were not very aggressive but at least the goals are there and that's something that leadership will pay attention to."

Let's take a closer look at the five priorities outlined in the HAI Action Plan:

Priority 1: Enrollment in NHSN for Nursing Home Infection Surveillance Activity
One of the largest challenges in addressing HAI prevention in long-term care is the lack of universally applied methodology and infrastructure to support infection surveillance activities in LTCFs. To address this gap in infection surveillance data collection infrastructure, the new NHSN LTCF Component was developed to promote and facilitate infection surveillance specifically for LTCFs. One of the core purposes of this tool is to support HAI prevention efforts and process improvement work by individual facilities.

The use of the NHSN LTCF Component could help facilities demonstrate their commitment to ongoing Quality Assessment and Performance Improvement (QAPI) activity. In 2013, all NHs will be required to have a QAPI program in place. The quality assessment aspect of the QAPI program is often a challenge for health care providers because of limits of their ability to collect or analyze their own care processes and outcomes data.

The reduction of HAIs is an excellent goal for facilities initial QAPI projects for multiple reasons. First, improving resident outcomes and reducing costs by addressing preventable HAIs would have high impact. Second, the LTCF Component of NHSN can provide facilities with standardized data collection tools that will reduce variation in the application of the criteria used by facilities to define HAI events. Third, it will provide an external surveillance system to monitor and analyze data on the incidence of HAIs in their facility. This would provide an essential feedback loop (quality assessment) for facilities to determine their baseline rates of HAIs, perform root cause analyses, and collect ongoing data to assess the impact of their prevention initiatives (performance improvement).

This alignment with NHSN and the QAPI initiative would benefit all long-term care stakeholders. For instance, it would provide the public health and payor communities with data to both monitor HAIs in long-term care and drive down costs associated with these preventable events across the care continuum. The providers and customers would benefit greatly from this because NHSN would provide the facilities with crucial data for their own quality initiatives that could shift their costs to prevention and improve the health of the residents. Additionally, with sufficient LTCFs reporting data in the NHSN system, national HAI benchmarks can be determined, allowing for meaningful interpretation of data and facilitating evaluation of the impact of implemented prevention efforts. Tracking increases in the number of LTCFs using NHSN over time can be a way to track the successful implementation and adoption of the NHSN LTCF Component. However, given that this is a new reporting system for nursing home users, there should be opportunity to pilot and obtain feedback on the ease in which providers can access the system and assess the validity of the data submitted. Therefore, a controlled implementation of the use of NHSN by LTCFs has been proposed that will ensure that reporting requirements and tools meet usability requirements and support improvement nationally.

Proposed metric:
Number of certified nursing homes enrolled into the NHSN LTCF Component / Number of certified nursing homes in the U.S.

Goal: 5 percent of certified nursing homes enroll in NHSN over the five years following launch of the component.

Priority 2: Clostridium difficile Infection
CDI surveillance using laboratory identified (Lab ID) events as a proxy measure has been incorporated as a reporting option within the NHSN LTCF Component. As in other healthcare settings, there may be some limitations to using Lab ID events within the LTCFs because access to microbiology labs and stool testing practices vary across facilities. The Lab ID event surveillance methodology has been well tested and adopted by CMS for the IPPS fiscal year 2012 rule for inpatient acute-care facilities. The LTCF Component Lab ID event uses the same definitions as the acute care reporting to maintain a standard methodology across care settings. Data from a small pilot indicate that Lab ID event methodology is feasible in nursing homes. This methodology provides a simple and standardized approach to performing CDI surveillance in the long-term care setting.

Proposed metric:
Incident NH-onset CDI Lab ID events: Number of events/10,000 resident days
o Incident lab events are defined as no previous positive or last prior positive more than eight weeks ago.
o Only events occurring more than three calendar days after resident admission are considered NH-onset.

Goal: Pilot implementation of reporting to NHSN, evaluate variability in measure, and obtain consensus on measurable five-year goal.

Priority 3: Vaccination for Residents (Influenza, Pneumococcal)
Vaccination for seasonal influenza and pneumococcus are widely available and highly effective in reducing the risk of infection events in older adults; therefore, LTCF resident influenza and pneumococcal vaccination have been selected as the priority measures. CMS has required the reporting of resident vaccination status for influenza and pneumococcus through the MDS for both short-and long-stay residents since 2005. Data from the first six months of use of the newest version of the MDS show long-stay residents with higher rates of vaccination for seasonal influenza and pneumococcus (81.7 percent and 79.8 percent, respectively) than for short-stay residents (60.1 percent and 61.2 percent). Our proposed goal is a combined rate for both short-and long-stay residents and is in line with the Healthy People 2020 goal of 90 percent vaccination coverage for both seasonal influenza and pneumococcal disease (IID-12.8 and IID 13.3).

Proposed metrics:
Number of residents receiving influenza vaccine either within the facility or outside the facility during the current or most current influenza season / Number of residents eligible for the influenza vaccine
Number of residents receiving pneumococcal vaccine or who are up-to-date with their pneumococcal vaccination / Number of residents eligible for pneumococcal vaccine

Goal: HHS proposes a goal of 85 percent vaccination coverage of LTCF residents for seasonal influenza and pneumococcus in five years.

Priority 4: Healthcare Personnel Influenza Vaccination
Increasing influenza vaccination coverage among HCP is a national priority, as indicated by the inclusion of a chapter in Phase Two of the HAI Action Plan. The proposed goal is in alignment with the influenza vaccination of HCP chapter of the HAI Action Plan and the Healthy People 2020 goal of increasing the percentage of HCP receiving the seasonal influenza vaccine each year to 90 percent using the National Health Interview Survey (NHIS) conducted by CDC. The most current NHIS data are from the 2007-2008 season, in which HCP working in long-term care trailed HCP in acute care settings in reporting receiving the influenza vaccine (36.2 percent compared with 63.4 percent). Data from an Internet panel survey conducted by CDC for the 2009-2010 influenza season indicated that this gap was closing with 71.1 percent of HCP in acute care hospital settings.

Proposed metric:
Proportion of HCP who work in long-term care who received the seasonal influenza vaccine as measured by NHIS

Goal: In alignment with the previous influenza vaccination of HCP chapter, 75 percent of HCP in long-term care receive the seasonal influenza vaccination by 2015.

Priority 5: Urinary Tract Infections, Catheter-Associated Urinary Tract Infections, and Catheter Care Processes
UTIs are consistently one of the highest reported infections in LTCFs. They account for a significant proportion of hospital admissions and emergency department visits. Due to this high prevalence, UTIs are a priority in LTCFs, though we must emphasize the importance of reporting only symptomatic UTIs to avoid promoting the antibiotic treatment of ASB and the associated consequences from antimicrobial misuse and overuse in this population. The future measure will need to take this emphasis into account; for example, the NHSN long-term care UTI definitions identify symptomatic infections by incorporating criteria captured through prospective surveillance using relevant clinical data from medical record review. Laboratory tests, while part of the surveillance definition, are not the sole means for identifying UTI events. The combination of signs, symptoms, and confirmatory laboratory data should minimize the inclusion of ASB within UTI event reporting. As the NHSN LTCF Component and other surveillance systems are developed, we will look to obtain consensus on what data source(s) to use.

Proposed metrics:
Non-catheter-associated symptomatic UTI incidence rate: Number of events/1,000 resident days
Catheter-associated symptomatic UTI incidence rate: Number of events/1,000 catheter days
Catheter utilization ratio: Catheter days/resident days
Goal: Pilot reporting to NHSN, evaluate variability, and obtain consensus on measurable five-year goal.

References
HHS National Action Plan to Prevent HAIs, chapter 8. April 2013.
Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, Mody L, Nicolle L and Stevenson K. SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. Am J Infect Control. July 2008.

Siegel JD, Rhinehart E, Jackson M, Chiarello L, Hicpac. Management of multidrug-resistant organisms in healthcare settings, 2006.
Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf/.

Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf/.

The Long-Term Care Workforce: Can the Crisis be Fixed? Problems, Causes and Options. Report prepared for National Commission for Quality Long-Term Care by the Institute for the Future of Aging Services. January 2007.

Resources:
Long-Term Care Toolkit: http://www.cdc.gov/HAI/settings/ltc_settings.html
Prevention Toolkits:  http://www.cdc.gov/HAI/prevent/prevention_tools.html#ltc