The changing role of infection-control programs in long-term care management.

Nosocomial infections are the major source of morbidity and mortality in long-term care facilities. (1) Over the past two decades, the prevalence of infection in long-term care settings has been documented between 5.4 and 32.7 per 100 residents per month, and infection incidence rates have been documented between 1.5 and 9.4 per 1,000 resident days. (2,3-8) An estimated 1.5 million infections occur annually in long-term care facilities in the United States. (9) Facility-acquired infections account for 30% of all hospital admissions from nursing homes (10) and are the most common immediate cause of death in nursing home residents. (11)

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The increasing incidence of new drug-resistant microorganisms such as Clostridium difficile, Streptococcus pneumoniae (pneumococcal pneumonia), methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum beta-lactamases (ESBLs) requires well-developed infection-control programs. In addition, the hospital payment system is causing a shift of sick and terminally ill patients to be moved from the hospital setting to nursing homes, with a subsequent increase in nursing home deaths. Therefore, infection-control practitioners (ICPs) are no longer only an option, but a necessity.

Facilities must have a program for detecting, preventing, controlling, and reporting infections. An infection-control program should address areas such as food handling, laundry, waste disposal, employee health, pest control, visitation, asepsis, quality control, and safety. This would include the development of policies and procedures for such things as isolation and handwashing. The key element of an infection-control program includes a well-trained ICP who is knowledgeable in basic microbiology and familiar with resident care problems. Because of the decreased availability of physicians in nursing homes and the fact that the elderly tend to have many underlying chronic diseases that increase their risk for infection, the ICP has greater responsibility for the diagnosis and prevention of infections.

Components of an effective infection-control program include surveillance, outbreak investigation, education, policies and procedures, an employee health program, a resident health program, environmental control, antibiotic monitoring, a performance improvement program, and cost containment. Each component is explained as follows:

Surveillance. Surveillance consists of collecting and evaluating data. The ICP must be able to differentiate between infection and colonization. Knowing a facility's baseline infection rates will help the ICP identify an outbreak situation early. While the ICP is performing surveillance duties, it is a great time to provide education to other staff members to assist in keeping the infection rates low. Surveillance can also be used to monitor the progress of an individual resident who has an infection and assist in the development of education programs.

Outbreak investigation. A key component of surveillance is the ability to identify outbreak situations. Early detection is the best way to limit the number of residents who will become infected and, at the same time, decrease the cost of the outbreak.

Education. Ongoing changes in federal and state infection-control regulations and guidelines require continuous staff education by the ICP. New employees must understand their role in preventing infection, as well as how they can avoid transmitting infections to residents. Education must include handwashing, standard precautions, immunizations, review of policies and procedures, aseptic practices, the facility's isolation procedures, and the importance of maintaining good personal hygiene.

Policies and procedures. A facility's policies and procedures must be continuously updated to reflect changes in regulations and guidelines, as well as changes in facility practices. Policies and procedures should cover all areas of the facility, including employee health, isolation, disinfection/sterilization, laundry, housekeeping, dietary services, engineering, waste disposal, resident visitations and, most importantly, handwashing. These policies should be readily available to all staff.

Employee health program. An active employee health program can accomplish two things. First, it will prevent employees from spreading infections to the residents; and second, it will prevent employees from contracting an infection while at work. Elements of an effective employee health program include: screening new employees for infectious diseases, educating employees about their role in transmission of nosocomial infections, updating employee immunization, periodically screening for infectious diseases (such as tuberculosis), ensuring employee safety from bloodborne pathogens (standard precautions), and investigating employees as potential agents for the spread of infectious disease during outbreaks.

Resident health program. A resident health program is aimed at issues such as resident hygiene, skin care, Foley catheter care, aspiration prevention, TB screening, and immunization for pneumococcal pneumonia and influenza.

Environmental control. The ICP is responsible for monitoring the inanimate environment, including the cleanliness of the residents' environment. The ICP should have basic knowledge of environmental services and engineering service areas, including ventilation, cleaning of environmental surfaces, waste disposal, and food preparation, as well as insect and rodent control. All cleaning supplies should be reviewed by the ICP annually, as well as any time a product is changed, to ensure that cleaning products are useful against the microorganisms seen in the facility.

Antibiotic monitoring. With the increase of microorganism-resistant antibiotics, there should be continuous monitoring of the appropriate use of antibiotics. Antibiotic monitoring enables the facility to identify any resistance pattern that may develop. Increased antibiotic resistance will continue to have a financial impact on all healthcare facilities.

Performance improvement program. Nursing homes are required to have a performance improvement program that emphasizes continued improvement in the care and health of its residents. Infection-control programs are similar to performance improvement programs in that both use data collection and analysis to improve resident care and decrease the risk for adverse outcomes. Both also rely on education to modify staff or resident behavior.

Cost-effectiveness. Although some products needed for patient care are expensive and may not be worth the money, the cheaper product may not always be the best choice either. Facilities must remember the overall mission of healthcare facilities is to optimize health. To reconcile the need for fiscal responsibility with optimizing health, facilities need to closely analyze both costs and outcomes. Cost-effectiveness refers to care outcomes and is expressed as the number of infections prevented or the number of lives saved. With cost-benefit analysis, the outcome is solely monetary. A well-run infection-control program should look at cost-effectiveness and cost benefits when making decisions on how programs should be run. The future of infection control will be challenging for all healthcare facilities with the emergence of new resistant microorganisms, the threat of bioterrorism, and the increasing ability of infectious diseases to jump species, such as the threat of avian influenza and the possible resurgence of SARS.

Senior care facilities have a legal and moral obligation to minimize the risk of infections to their residents and staff. Many facilities lack experienced infection-control personnel. With rising costs and shrinking budgets, facilities tend to consider medical interventions that favor minimizing cost. Optimizing healthcare with fiscal responsibility is the overall mission of any medical facility. Facilities need to be committed to their infection-control programs and provide ongoing guidance and education to their ICP. And ICPs need the support of administration to perform their required duties and to develop the necessary expertise. Strong administrative structure, committed personnel, and ongoing evaluation will help ensure the success of an effective infection-control program.

Linda L. Spaulding, RN, C; CIC, is the founder and CEO of InCo and Associates, LLC, an international infection-control consulting firm based in Lakewood Ranch, Florida. The firm specializes in program development, staff education, surveillance, and outbreak investigations focusing on JCAHO, state departments of health, and OSHA preparedness. For more information, call [phone] or visit www.incoandassociates.com. To send your comments to the author and editors, e-mail [e-mail].

References

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10. Irvine PW, Van Buren N, Crossley K. Causes for hospitalization of nursing home residents: The role of infection. Journal of the American Geriatrics Society 1984;32:103-7.

11. Rudman D, Mattson DE, Nagraj HS, et al. Antecedents of death in the men of a Veterans Administration nursing home. Journal of the American Geriatrics Society 1987;35:496-502.

Linda L. Spaulding, RN, C; CIC, explains how a well-run infection-control program can benefit long-term care