Understanding Long-Term Care's Unique Challenges

By Kelly M. Pyrek

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. In January, 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.

Infection preventionists in LTCFs face unique challenges due to the nature of the care setting and its aging resident population. An estimated 1.5 million infections occur annually in LTCF, resulting in 350,000 to 400,000 deaths. “APIC is committed to increasing educational resources for long-term care to advance knowledge and competencies of healthcare personnel working in this setting, and for the benefit of the residents under their care,” says APIC CEO, Katrina Crist, MBA. “With more than 15,000 long-term care facilities in the United States, and a national priority to prevent healthcare-associated infections, APIC’s new book guides LTCFs through the essential components of an evidence-based infection prevention program.”

The Infection Preventionists Guide to Long-Term Care 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 infection 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 million 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. Transfer 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 hand rub 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 multi-drug 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."