Infection Control Across the Board.

Reducing and eliminating resident infections involve nearly every aspect of facility operation

Maturing and elderly adults living in long-term care facilities, because of their age-related decline in resistance, daily face potential threats to their health from the spread of urinary tract and respiratory infections (influenza, pneumonia), infected pressure ulcers, gastroenteritis, conjunctivitis and other bacterial and viral infections. In fact, the Centers for Disease Control and Prevention (CDC) estimate that 1.5 million nosocomial (acquired after admission) infections occur in long-term care residents annually. What's more, in addition to acquiring nosocomial infections, some residents enter the long-term care facility with already chronic infections.

Infections of any origin can easily spread in this environment as residents, employees and visitors come into daily contact. Transmission can be via direct contact, airborne, through a vehicle (e.g., food or water) or vectorborne (via rodents and other pests).

Staff should take measures to minimize opportunities for cross-contamination-from something as simple as following appropriate hand washing and food handling procedures to addressing more complex issues, such as ventilation and employee training. Reducing cross-contamination involves all areas of facility design and management.

Facility Services

Opportunities to minimize cross-contamination exist throughout facility services functions, including laundry, housekeeping and equipment cleaning.

Laundry. While rare, there are opportunities during the laundry cycle for the dissemination of microorganisms. For example, scabies, a contagious skin infection, can be transmitted by linen and clothing. If sheets are not rolled when removed, airborne bacteria can quadruple in the resident's living area or room and potentially double in the hallway. Soiled linens should be bagged and then transported, preferably in covered containers, which should be regularly cleaned. Sorting soiled linen before washing also minimizes exposure of facility and laundry personnel to potentially infectious material. A hot-cycle wash should be used, and clean linens should be stored in covered containers or shelves. Facility personnel should always wash their hands after handling soiled linen.

Housekeeping. Three types of cleaning methods are used in long-term care facility housekeeping: sanitation, decontamination and disinfection. Sanitation, which is all that most surfaces in long-term care facilities require, refers to simply reducing the number of microorganisms to a safe level. A sanitized surface is clean and free of gross soil. Kitchen surfaces, dishes and cooking utensils should be sanitized. Decontamination refers to the process of removing disease-producing organisms to make a surface or items safe for handling, e.g., cleaning a blood spill with a bleach solution. Disinfection is the process of killing most disease-producing organisms. Table 1 offers cleaning guidelines from the Association for Professionals in Infection Control and Epidemiology (APIC).

Equipment cleaning. CDC guidelines for equipment cleaning and disinfection address surgical instruments and catheters, respiratory equipment, bedpans, crutches, water glasses, food utensils, wheelchairs, carts, walkers, beds, mattresses, physical and respiratory therapy equipment, and thermometers, among other devices. Table 2 shows examples of how various devices should be cleaned. Disposable equipment and supplies can sometimes be a cost-effective option, but they should never be processed and reused.

Waste management. Most liquid or semiliquid items contaminated with blood and other body fluids are considered infectious waste. Contaminated sharps also can transmit disease via direct subdermal inoculation. These include hypodermic needles, scalpels, blades, pipettes and broken glass. Miscellaneous contaminated waste includes wastes from patients infected with bloodborne diseases and laboratory wastes.

Infectious waste should be placed in adequately large, leak-proof, tear-resistant bags or containers and should be color-coded or labeled. They should be closed before removal to prevent spilling. Disposable sharps should be packaged or maintained in puncture-resistant, leak-proof containers with a red or "biohazard" label. These containers or needle boxes must not be overfilled to the point where they won't close. Tape can be used to secure the lids of sharps containers for storage, handling and transport.

Infectious waste should never be compacted. Glass, reusable needles or contaminated equipment should be picked up with a tool; and employees should not reach into containers to clean sharps.

Infectious waste should be stored in a protected area, away from unauthorized personnel and environmental elements. Storage time should be short, and the storage area should be labeled with a "biohazard" symbol. This waste should be properly treated prior to disposal, according to local regulations. Blood, blood products and body fluids can be poured into an approved sewer disposal system. These can also be steam-sterilized or incinerated. Sharps can only be incinerated or steam-sterilized.

Moving infectious waste to a landfill must be done by individuals with appropriate permits, and carts used to transport it must be disinfected. Garbage, especially from the kitchen, must be removed from the building, stored as far from the entrance as possible and placed on a concrete surface. Plastic bags of garbage should be placed in a rigid container with a cover, and garbage containers should have tight-fitting lids.

Pest control. Nontoxic chemicals should be used for pest control and placed both inside and outside the foundation of all buildings.

Food Handling

Poor hygiene, inadequate cooking and improper food handling and storage carry the potential for foodborne illness. Foodservice employees should be in good health and practice proper hygiene and food-handling procedures, including hand washing and wearing appropriate protective apparel, such as gloves and hairnets. Other means for preventing cross-contamination and the spread of infection in foodservice settings are listed in Table 3.

The Physical Plant

A number of factors can contribute to cross-contamination in the building itself. Considerations include facility design, restroom products, building materials, plumbing and ventilation. The American Institute of Architects offers "Guidelines for Construction and Equipment of Hospital and Medical Facilities" for overall guidance. Areas that deserve special attention are outlined in Table 4.

Infection-Control Programs! Training

While facilities' infection-control programs vary, there are some cross-contamination guidelines that everyone can follow. According to APIC, no policy or procedure is more important than that of addressing employee hand washing. The policy should detail specific indications for hand washing (including when employees come on duty; whenever hands are soiled; after use of the toilet; after blowing or wiping one's nose; after contact with resident blood or body secretions; before performing invasive procedures; after leaving an isolation room; after handling dressings, bedpans, catheters or urinals; after removing gloves; before eating; and on completion of duty). Hand washing compliance should be monitored for all employees. Visitors also should be instructed on proper hand washing techniques and the use of masks and gloves (as necessary) in providing direct care for an at-risk resident.

Isolation of residents might be needed to guard against spreading infectious diseases and major wound infections. Rooms used for isolation or precautions should have readily accessible toilet and hand washing facilities and should be identified by precautionary signs.

The newest CDC isolation guideline is a two-tiered system consisting of basic Standard Precautions and additional Transmission-Based Precautions. While developed for hospitals, these guidelines also can be applied to long-term care facilities.

Standard Precautions are to be applied to all patients to reduce the risk of transmission of infectious agents in moist body secretions. These emphasize hand washing, gloves (when touching body fluids), masks, eye protection and gowns (when splashing of body fluids is likely), as well as avoidance of needlestick and other sharps injuries. Standard Precautions involve body substance isolation or barriers and focus on caregivers' routine interactions with residents. Guidelines are presented in Table 5.

Transmission-Based Precautions, which include Airborne Precautions, Droplet Precautions and Contact Precautions, are for patients with documented or suspected contagious pathogens. The CDC guidelines list specific symptoms that indicate infection and suggest using Transmission-Based Precautions temporarily until a diagnosis is made.

Additional Considerations

New employees should provide a health history at the time of hire. Employment information relevant to infection control includes: history of chronic skin diseases, chickenpox, measles, hepatitis, medications use, underlying medical problems, tuberculin skin testing, history of immunizations and bacterial diarrhea. Those who have not been immunized against diphtheria and tetanus in the prior 10 years should receive a booster immunization, and employees should have repeat vaccinations every 10 years. Individuals who are hired in fall or winter should be immunized against influenza, and all staff should get annual flu shots.

Under current OSHA regulations, hepatitis B immunizations must be administered to employees who are/might be exposed to blood or body fluids. Extensive information on vaccines can be found in the CDC's "Update on Adult Immunizations" and the American College of Physicians' "Guide for Adult Immunization."

If a resident's immunization status is in doubt, an initial series should be administered. Influenza vaccine should be given to residents over 65 and those with congenital heart disease, chronic pulmonary disease, diabetes mellitus and immunosuppressive disorders, including malignancies. Vaccine to protect against Streptococcus pneumoniae is also recommended for certain elderly residents (those with splenic dysfunction or anatomic asplenia; and those with chronic diseases associated with an increased risk of pneumococcal disease, such as sickle cell anemia, multiple myeloma, cirrhosis, renal failure, diabetes mellitus, congestive heart failure, chronic lung disease and immunosuppressive diseases, including malignancies).

Residents should be instructed in hygiene and hand washing as appropriate to their functional status. Because the skin itself is a barrier to infection, resident skin-care programs should include routine, frequent turning for those unable to do so themselves, keeping residents clean and dry, routinely inspecting resident's skin, ensuring proper nutrition and treating pressure ulcers.

Finally, be sure to consult your state for infection-control requirements for licensure and make sure you have a comprehensive infection-control program in place.

Amy Walker Barrs is healthcare market segment manager for the Away From Home Sector, and Pam Fahey, RN, BSN, is with Health Services, Kimberly-Clark Corporation, Roswell, Georgia.

Basic Cleaning Tips from APIC.

* Work from the top to bottom of a room and from the least to most contaminated areas.

* Remove debris before mopping.

* Change cleaning solutions and mop heads often (the dirtier the cleaning project, the more frequently the solution and mop head should be changed).

* Use a closed cleaning system that provides a new products (such as wipes) every time.

* Store all equipment clean at the end of the day.

* Monitor environmental cleanliness by walking rounds with a checklist for each area of the facility.

3. Food Handling Guidelines.

* Check freshness dates.

* Check temperature of refrigerated delivery trucks.

* Make sure all staff know when food is delivered, and rotate stock.

* Make sure cold foods are stored at suggested temperatures, usually about 42[degrees] F.

* Store and thaw foods properly.

* Sanitize cutting boards after use.

* Thoroughly wash all fruits and vegetables (even if they will be peeled).

* Train employees in food sanitation procedures.

* Calibrate oven or grill temperatures.

* Devise an equipment-cleaning system and timetable.

* Have a regular mopping schedule to keep floors clean.

* Sanitize sponges and run through the dishwasher.

* Make sure there are dedicated hand sinks with no-touch soap dispensers, hand sanitizers and hands-free towel and bath tissue systems.

* Train staff to wash and sanitize hands before work, after using the bathroom and between the different foods they handle during preparation.

* Prohibit employees with potentially infectious skin lesions from having contact with residents' food.

* Limit food and drink to specific areas.

4. Useful Measures for Areas of Special Concern.

Restrooms

* No-hands dispensers for towels, soap, tissues, etc.,

* Key cards for entering public bathrooms

* Faucets with electronic sensors to control water

* Light sensors that turn on lights when someone enters the restroom (After a set time, the lights go off unless another individual enters the room.)

* Automatic urinal- and toilet-flushing devices (Some of these flush automatically when not in use to keep fresh water in the bowl, thus reducing bacteria formation.)

Building Materials

* Selected for ease of cleaning and maintenance

* Able to resist deterioration and cracking

* Hard-surface flooring or short-looped carpets preferred (easier to clean)

Plumbing

* Routine preventive maintenance (poorly functioning drains can allow water to accumulate and lead to the growth of microorganisms.)

* No leaking pipes in areas of food preparation, clean storage or above ceiling tiles (can lead to fungus growth)

* Routine inspection of shower heads (Bacteria implicated in Legionnaire's disease have been shown to contaminate them; solutions: hyperchlorination and superheating.)

Ventilation

* Filters to catch bacteria and fungi

* Humidity and temperature levels monitored/controlled

* Air pressure/number of air exchanges monitored (CDC and OSHA recommend negative air pressure with at least six air exchanges per hour for tuberculosis control.)

* No recirculation of air unless it passes through a high-efficiency filter (it should be direct-exhausted to the outside.)

* Use of HVAC contractors with experience in long-term care facilities

Body Substance Isolation System. [*]

Gloves:

They should be worn when hands might/will be in contact with mucous membranes, nonintact skin and/or moist body substances or items/surfaces soiled with them. Examination gloves should be used in most indications and changed between residents.

Hand washing:

Hands should be washed often and well, especially between fingers and under fingernails.

Face/eye protection:

When it is likely that eyes and/or mucous membranes will be splashed with body substances, masks and/or eye protection should be used.

Apron or gown:

If it is likely that clothing will be soiled by body substances, it is suggested that a plastic apron or gown be worn.

Laboratory specimens:

To avoid needlestick injuries, don't recap needles; dispose of them in a puncture-resistant container.

(*.) to be followed by all personnel at all times, regardless of resident diagnosis