Infection Prevention in Outpatient, LTC Facilities

By Kelly M. Pyrek

As healthcare delivery evolves, institutions and systems are expanding their campuses to include ambulatory and long-term care facilities. And for infection preventionists working in stand-alone facilities, they must stay up to date on infection prevention imperatives.

Ambulatory Care

High-profile outbreaks in ambulatory surgery centers in recent years have given the industry a black eye and prompted agencies such as the Centers for Medicare and Medicaid Services (CMS) to issue new conditions for coverage that are designed to bolster infection prevention and control knowledge and implementation in outpatient care. Specifically, the ASC must maintain an infection control program that seeks to minimize infections and communicable diseases, provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases, and to and achieve the following: be based on nationally recognized infection control guidelines; be directed by a designated healthcare professional with training in infection control; be integrated into the ASCs QAPI program; be ongoing; include actions to prevent, identify and manage infections and communicable diseases, and include a mechanism to immediately implement corrective actions and preventive measures that improve the control of infection within the ASC.

Peggy SaBell, RN, MS, CIC, director of a regional infection control program for Kaiser Permanente in Colorado, emphasizes the importance of conducting risk assessments. "My perception, after working in ambulatory care for many years, is that we must be very clear about where our risks are and conduct a thorough risk assessment," SaBell says. "Our hospital peers are conducting risk assessments for their setting, and we need to do the same for ours, drilling down to where our risks are in order to plan our programs and our interventions around them."

SaBell provides an example of the inherent challenges of identifying the risks encountered in ambulatory care: "Let's say someone shows up for surgery and has a draining wound. You may culture it or the patient may go to the hospital and have it cultured, but you are still taking care of a patient for whom you are awaiting results. Or a patient has diarrhea and no cultures have been performed and we don't know if it's C. difficile. The point is that in ambulatory care, many times we isolate and perform our actions around general rather than specific information -- we are simply trying to provide care around the draining wound or the diarrhea, instead of being able to respond to the identified risk. So this is why it's so important to pinpoint where the risks are. Anytime you have a procedural setting, there are risks everywhere and one of those is safe injection practices. That's something we have to look at in all healthcare settings."

The new Guide to Infection Prevention in Healthcare Settings, produced by the Centers for Disease Control and Prevention (CDC), outlines the minimum expectations for safe patient care and serves as a summary guide of infection prevention recommendations for ambulatory care settings. It acknowledges the strides that still need to be made in infection control in outpatient care: "Compared to inpatient acute care settings, ambulatory care settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities. While data describing risks for HAI are lacking for most ambulatory settings, numerous outbreak reports have described transmission of gram-negative and gram-positive bacteria, mycobacteria, viruses and parasites. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures (e.g., reuse of syringes leading to transmission of bloodborne viruses)."

Two trends are melding to create a perfect storm: over the past several decades there has been a significant shift in healthcare delivery from the acute, inpatient hospital setting to a variety of ambulatory and community-based settings, and the acuity levels are rising quickly as healthcare workers must content with patients who are sicker and have numerous co-morbidities.

"We are seeing patient acuity levels climbing higher every year and we're doing more procedures in the outpatient arena annually," SaBell confirms, adding that as the sophistication of the care required grows, so do the infection prevention strategies. "Any time you are doing invasive procedures, strict infection control measures must be in place, and it's the same standards we must uphold like our hospital peers do. Strategies like good hand hygiene crosses through all of the different healthcare settings, of course. So do proper disinfection and sterilization of surgical instruments and devices, as well as environmental hygiene -- it's the same whether you are in acute care, ambulatory care or long-term care. These are principles that must be adhered to across the board."

SaBell continues, "Good training in aseptic technique will see a nurse through everything. I suspect that some individuals in ambulatory care have been lulled into thinking that infection control isn't as important as it is in acute care, and perhaps they didn't stay current on infection control as well as they should have. The basics of good aseptic technique or good hand hygiene apply to everyone."

And as the aforementioned CDC guide emphasizes, "All healthcare settings, regardless of the level of care provided, must make infection prevention a priority and must be equipped to observe Standard Precautions." Standard Precautions are defined as the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect healthcare workers and prevent these personnel from spreading infections among patients. Standard Precautions include: hand hygiene; use of personal protective equipment (e.g., gloves, gowns, masks); safe injection practices; safe handling of potentially contaminated equipment or surfaces in the patient environment; and respiratory hygiene/cough etiquette. As the guide notes further, "Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence."

Carol Imes, RN, MPA, CNOR, director of the Mentor Surgery Center in Mentor, Ohio, says she believes in the power of education to help ambulatory care professionals stay current with best practices. "Ambulatory surgery managers continue to work hard to meet the CMS regulations," she says. "Continue to read every thing you can on infection control practices. Read professional magazines and articles. Attend webinars and seminars. The infection control nurses received their initial training in infection control, but it is best practice to get annual training. Take another look at the regulations since we have had time to work on the most pressing issues and now can look for things we may have missed when the standards were first released. And have at least one staff member be a member of AORN and APIC so you can keep with the latest information on infection control."

Imes continues, "All of the ambulatory managers I know have taken the CMS mandates very seriously and continue to make improvements in infection control. Personally I have thought that ambulatory centers have been always been aggressive in their infection control and historically have very low infection rates. However, I am increasing the handwashing audits and making more observations. I am trialing disinfectants with a 2- to 3-minute kill time since our turnover time is short. We have always investigated infections that occur in our center, and the surgeons are reporting them more quickly than before. All my staff is much more cognizant of infection control practices."

Many ASCs have now experienced a CMS survey to which the infection control conditions for coverage have been applied, and SaBell emphasizes that "it's critical for us to examine the areas that CMS will be looking at because doing so gives us a good idea of what the risks are in our setting." SaBell adds, "I think the dust is starting to settle, and while there are still some struggles, more CMS survey-related education and networking opportunities are available from APIC and others than ever before. I went to a seminar recently where the target audience member was a new infection preventionist or the person in the ASC who is now handling infection prevention; one of the speakers was a CMS auditor and safe injection practices was the main subject of the presentation -- that tells me CMS is getting serious about this topic. I think we have a better idea of what CMS is looking for -- they want an integrated infection control program and they want to see that we are actually keeping track of things like hand hygiene done pre-operatively, perioperatively and post-operatively. As more ASCs get surveyed, more information is being shared; for example, I have talked to a lot of people about our survey, what CMS surveyors were looking at and how to prepare. It's still a work in progress because we still need to identify within our organizations the practices that must be changed. I think we now know where we are going with our programs and it's a matter of getting additional administrative support in our centers, and changing some long-held practices."

Instigating a culture change is one of the most daunting tasks an infection preventionist faces, and SaBell agrees it's not an overnight fix. "It's more difficult to bring about a culture change because many ambulatory care providers think that we just get healthy people as patients and that's rapidly changing," she says. "Plus, the infection control message may not be as in your face as it is in the hospital setting -- for example, people may do a better job of washing their hands in the hospital because that message is being driven home a lot harder. Certain habits or practices are more difficult to improve because they more ingrained. In hospitals there is more education whereas in outpatient centers there is an over-riding focus on getting patients in and out quickly and infection control may be taking a back seat. Providing the best care and never letting things slide is absolutely imperative -- we must never say to ourselves, 'Well, we have a low infection rate, so we don't really need to focus on infection control.' We don't ever want to become complacent."

SaBell continues, "We must continually look at our processes and our outcomes to identify areas needing improvement, whether it's by doing more education or intervening when something is not being done in the right way. We moved our hand sanitizer dispensers to where the patients are, right there in pre-op or in recovery, so they see the nurses performing hand hygiene. We must make it very clear to our patients what we are doing to prevent infections. Much of our post-op patient instruction focuses on preventing infections. We want patients to be able to attest that they received really good care and that they saw staff washing their hands or scrubbing the hub of their IV."

Implicated in many outbreaks in ambulatory surgery centers are contaminated surgical instruments and scopes that have not been cleaned, disinfected and sterilized properly, so it is essential that outpatient facilities establish and follow policies and procedures for containing, transporting, and handling equipment that may be contaminated with blood, body fluids and other potentially infectious material.

"I think there is still confusion about immediate-use sterilization and what is acceptable and what is not," says Imes. "As a nurse, I have had to learn about sterile processing, sterilizers, settings, special requirements for power equipment. I rely a lot on my central processing personnel. We have purchased many instruments trays so we do not have to worry about having sterile instruments when we have quick turnover times. Look at your instrument sets and duplicate ones that you use frequently. Educate staff to be vigilant in checking autoclave tapes and indicators to make sure all parameters are met. Encourage staff to challenge each other if there is a break in sterile technique."

The aforementioned CDC guide makes the following recommendations for cleaning, disinfection and/or sterilization of medical equipment in ambulatory care settings:

1. Facilities should ensure that reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, surgical instruments, endoscopes) is cleaned and reprocessed appropriately prior to use on another patient

2. Reusable medical equipment must be cleaned and reprocessed (disinfection or sterilization) and maintained according to the manufacturers instructions. If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use

3. Assign responsibilities for reprocessing of medical equipment to healthcare workers with appropriate training

a. Maintain copies of the manufacturers instructions for reprocessing of equipment in use at the facility; post instructions at locations where reprocessing is performed

b. Observe procedures to document competencies of healthcare workers responsible for equipment reprocessing upon assignment of those duties, whenever new equipment is introduced, and on an ongoing periodic basis (e.g., quarterly)

4. Assure that healthcare workers have access to and wear appropriate personal protective equipment (PPE) when handling and reprocessing contaminated patient equipment

Long-term Care

Some of the most immuno-compromised and vulnerable patient populations reside in long-term care (LTC) facilities and these institutions can be hotbeds of healthcare-associated infections. A recent study in the American Journal of Infection Control (AJIC 2011; 39 [5]) revealed that 15 percent of U.S. nursing homes receive deficiency citations for infection control annually.

Conducted by a team of researchers at the University of Pittsburgh's Graduate School of Public Health, the study analyzed deficiency citation data collected for the purpose of Medicare/Medicaid certification between 2000 and 2007, representing approximately 16,000 nursing homes annually and a panel of roughly 100,000 observations. The records analyzed represent 96 percent of all U.S. nursing home facilities. The team discovered a strong correlation between low staffing levels and the receipt of an infection control deficiency citation.

Infections are the leading cause of morbidity and mortality in nursing homes, responsible for nearly 400,000 deaths per year. Although this has been the focus of mainstream media attention, very little empirical research has been conducted on the subject. The Centers for Medicare and Medicaid Services (CMS) requires that nursing homes be certified before receiving reimbursement for Medicare and/or Medicaid residents. As part of this certification process, facilities that do not meet certain standards are issued deficiency citations. This study examined the deficiency citation for infection control requirements known as the F-Tag 441.

"Our analysis may provide some clues as to the reason for the persistent infection control problems in nursing homes," state the study authors. "Most significantly, the issue of staffing is very prominent in our findings; that is, for all three caregivers examined (i.e., nurse aides, LPNs and RNs) low staffing levels are associated with F-Tag 441 citations. With low staffing levels, these caregivers are likely hurried and may skimp on infection control measures, such as hand hygiene." They add further, "The high number of deficiency citations for infection control problems identified in this study suggests the need for increased emphasis on these programs in nursing homes to protect vulnerable elders."

A number of states have enacted legislation that applies to infection prevention practices in long-term care facilities, and Illinois is poised to pass legislation requiring an infection preventionist in each skilled nursing facility. So as the country wrestles with the issue legislatively, infection preventionists working in long-term care should endeavor to uphold the best practices that are known to help control and eliminate infections in this patient population. A good guide to these practices can be found in the SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility (Infect Control Hospi Epidem. 29(9) Sept. 2008).

The LTC guideline acknowledges the clear differences between acute-care and LTC and the unique challenges of the LTC patient population, including differences in acuity levels, types of predominant infections, and the use of urinary catheters as well as the use of invasive devices such as central venous catheters, mechanical ventilators and enteral feeding tubes, which increase the likelihood of a device-associated infection. The SHEA/APIC LTC guideline points to the specific LTC-related infections that require strong infection control practices to curtail and prevent: urinary tract infection and bacteriuria; respiratory tract infections (especially pneumonia, influenza and tuberculosis); skin and soft-tissue infections (such as decubitus ulcers, cellulitis and even scabies). The real challenge is that many LTC-related infections are endemic and ongoing surveillance is required to detect epidemic clustering of transmissible, virulent infections. According to the LTC guideline, "Outbreaks must be anticipated, and ideally, infection control surveillance and practices should be the responsibility of frontline staff as well as infection control staff." The guideline adds, "An outbreak or transmission within the facility may occur explosively with many clinical cases appearing within a few days or may, for example, involve an unusual clustering of MRSA clinical isolates on a single nursing unit over several months. On the other hand, a case of MRSA infection may follow a prolonged period of asymptomatic nasal colonization after an aspiration event or development of a necrotic wound. Outbreaks in LTCFs accounted for a substantial proportion of reported epidemics. Clustering of URIs, diarrhea, skin and soft tissue infection, conjunctivitis, and antibiotic-resistant bacteriuria have been noted. Major outbreaks of infection have also been ascribed to E coli, group A streptococci, C difficile, respiratory viruses, Salmonella spp, Chlamydia pneumoniae, Legionella spp, and gastrointestinal viruses. Nursing homes accounted for 2 percent of all foodborne disease outbreaks reported to the CDC (1975-1987) and 19 percent of outbreak-associated deaths. Transmissible gastrointestinal pathogens may be introduced to the facility by contaminated food or water or infected individuals. High rates of fecal incontinence, as well as gastric hypochlorhydria, make the nursing home ideal for secondary fecal-oral transmission. Other epidemics include scabies, hepatitis B,127 group A streptococcal infections, viral conjunctivitis, and many other infections."

Despite all of these considerations, it is important to remember that some overarching principles apply to all healthcare settings, and not just LTC. As Gail Bennett, RN, MSN, CIC, an independent consultant with ICP Associates, Inc. based in Georgia, and one of the authors of the guideline, notes, "I definitely believe that the same infection prevention principles and practices that apply to acute care also apply to long-term care facilities (LTCFs) with the exception of some principles or practices that involve services not offered by the LTCF, e.g. ventilator associated pneumonia prevention, surgical site infection prevention, etc. The LTCF should be applying those principles as vigorously as acute-care facilities even though in my experience the LTC infection preventionist has even greater challenges to the infection control program than we do in acute care."

Bennett says that one those biggest challenges is "the very high staff turnover rate among front line workers as well as management staff, including the infection preventionist," she says. "When we lose those well trained, knowledgeable employees we lose an abundance of skills and knowledge that has taken quite some time to foster. This is definitely a human-resources issue and is probably best addressed by the LTC trade organizations. The second biggest challenge is the infection preventionist having dedicated time to do infection prevention. He/she wears multiple hats and many issues take precedence over the routine functions of infection prevention. We need some strong recommendations coming out of the LTC associations and perhaps from CMS (although from the provider side I am reluctant to say that) to actually give this issue more importance and urgency."

Bennett offers some advice to infection preventionists working in LTC facilities who may be sorely lacking in budgets, resources, FTEs, for their infection prevention programs: "There are so many wonderful resources available on the web that are free of charge that can really give the IP what he/she needs to advance their programs until the budget allows other resources to become available. The CDC prevention guidelines, APIC elimination guides, and the SHEA compendium of strategies for infection prevention are all excellent resources and they address many issues pertinent to LTCFs. Some LTC infection preventionists do not have their own computer at the facility but many of them are very resourceful and get what they need from the web at home. In my experience, infection preventionists from all arenas are self-motivated and work hard to overcome any obstacles to having a good infection prevention program."