Infection control programs in skilled nursing long-term care facilities: an assessment, 1995

Standardized Infection Surveillance in Long-Term Care Interfacility Comparisons From a Regional Cohort of Facilities

Objectives:

To measure infection rates in a regional cohort of long-term-care facilities (LTCFs) using standard surveillance methods and to analyze different methods for interfacility comparisons.

Setting:

Seventeen LTCFs in Idaho.

Design:

Prospective, active surveillance for LTCF-acquired infections using standard definitions and case-finding methods was conducted from July 2001 to June 2002. All surveillance data were combined and individual facility performance was compared with the aggregate employing a variety of statistical and graphic methods.

Results:

The surveillance data set consisted of 472,019 resident-days of care with 1,717 total infections for a pooled mean rate of 3.64 infections per 1,000 resident-days. Specific infections included respiratory (828; rate, 1.75), skin and soft tissue (520; rate, 1.10), urinary tract (282; rate, 0.60), gastrointestinal (77; rate, 0.16), unexplained febrile illnesses (6; rate, 0.01), and bloodstream (4; rate, 0.01). Initially, methods adopted from the National Nosocomial Infections Surveillance System were used comparing individual rates with pooled means and percentiles of distribution. A more sensitive method appeared to be detecting statistically significant deviations (based on chi-square analysis) of the individual facility rates from the aggregate of all other facilities. One promising method employed statistical process control charts (U charts) adjusted to compare individual rates with aggregate monthly rates, providing simultaneous visual and statistical comparisons. Small multiples graphs were useful in providing images valid for rapid concurrent comparison of all facilities.

Conclusion:

Interfacility comparisons have been demonstrated to be valuable for hospital infection control programs, but have not been studied extensively in LTCFs.

Impact of hand hygiene on the infectious risk in nursing home residents: A systematic review

BACKGROUND

In nursing homes, the infectious risk is high, making infection control using approaches such as hand hygiene (HH) a major issue. However, the effectiveness of HH in these settings is not well documented, and HH compliance is low.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for studies in nursing homes that either described a HH-related intervention or assessed HH compliance and included a measured infectious outcome. Two reviewers independently performed the study selection.

RESULTS

Fifty-six studies met the inclusion criteria and were reviewed. Most were outbreak reports (39%), followed by observational studies (23%), controlled trials (23%), and before-after intervention studies (14%). Thirty-five studies (63%) reported results in favor of HH on at least one of their outcome measures; in addition, the infection control success rate was higher when at least one HH-related intervention (eg, staff education on HH, increased availability of handrub solution) was included (70% vs 30% for no intervention). However, only 25% of randomized trials concluded that HH-related interventions led to a reduction in the infectious risk.

CONCLUSION

The results of this systematic review suggest that more evidence on HH effectiveness in nursing homes is needed. Future interventional studies should enhance methodologic rigor using clearly defined outcome measures, standardized reporting of findings, and a relevant HH observation tool.

Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes

BACKGROUND

Health care-associated infections are the leading cause of morbidity and mortality in US nursing homes (NHs). The objective of the research is to assess the impact of Maryland NH infection preventionists (IPs) on NH quality measures.

METHODS

Two hundred thirty-four NHs were queried through mailed survey. These survey data were then linked with 2008 quality data from Nursing Home Compare and the On-line Survey Certification of Automated Records.

RESULTS

Three of the 8 quality measures examined-influenza vaccination for both short- and long-stay residents and pressure ulcer prevention in high-risk residents-were significantly associated with the number of IPs. None of the quality measures were shown to be significant with IPs who received specialized training on infection prevention and management compared with those who did not receive specialized training.

CONCLUSION

IPs play a critical role in preventing and managing health care-associated infections in nursing homes, especially in the areas of influenza vaccination and pressure ulcer prevention among high-risk nursing home residents. Quality measures that reflect the effects of IP training may not have been elucidated yet. Further research is needed to support the IP role in order for policy to advocate for increased IP funding.

Hand Hygiene Practices Reported by Nurse Aides in Nursing Homes

Information from nurse aides describing their opinions of hand hygiene practices in nursing homes including perceived barriers to hand hygiene is presented. The information comes from a questionnaire developed for this investigation, with items addressing compliance, facility guidelines and protocols, training, hand washing facilities and materials, and hand washing barriers. Information from 4,211 nurse aides (response rate of 56%) working in a nationally representative sample of 767 nursing homes (participation rate = 51%) is used. We find that 57.4% of nurse aides comply with hand washing when caring for residents most of the time, while 21.7% always comply. With facilities, 43.3% sometimes check that hand washing is performed. In summary, self-reported compliance was poor, and facilities and materials were often lacking. These findings are useful in identifying issues and interventions, including the need for further initiatives to address hand hygiene practices.

Hand hygiene deficiency citations in nursing homes

Hand hygiene (HH) is recognized as an effective way to decrease transmission of infections. Little research has been conducted surrounding HH in nursing homes (NHs). In this research, deficiency citations representing potential problems with HH practices by staff as identified in the certification process conducted at almost all US NHs were examined. The aims of the study were to identify potential relationships between these deficiency citations and characteristics of the NH and characteristics of the NH environment. We used a panel of 148,900 observations with information primarily coming from the 2000 through 2009 Online Survey, Certification, And Reporting data (OSCAR). An average of 9% of all NHs per year received a deficiency citation for HH. In the multivariate analyses, for all three caregivers examined (i.e., nurse aides, Licensed Practical Nurses, and Registered Nurses) low staffing levels were associated with receiving a deficiency citation for HH. Two measures of poor quality (i.e., [1] Quality of care deficiency citations and [2] J, K, or L deficiency citations, that is deficiency citations with a high extent of harm and/or more residents affected) were also associated with receiving a deficiency citation for HH. Given the percentage of NHs receiving deficiency citations for potential problems with HH identified in this research, more attention should be placed on this issue.

Long-term care facilities in Utah: a description of human and information technology resources applied to infection control practice

BACKGROUND

Little is known about the implementation of infection control (IC) programs and information technology (IT) infrastructure in long-term care facilities (LTCFs). We assessed the IC human resources, IT infrastructure, and IC scope of practice at LTCFs in Utah.

METHODS

All LTCFs throughout Utah (n = 80) were invited to complete a written survey in 2005 regarding IC staffing, policies and practices, and IT infrastructure and capacity.

RESULTS

Responses were received from 62 facilities (77.5%). Most infection preventionists (IPs) were registered nurses (71%) with on-the-job training (81.7%). Most had other duties besides their IC work (93.5%), which took up the majority of their time. Most facilities provided desktop computers (96.8%) and all provided Internet access, but some of the infrastructure was not current. A minority (14.5%) used sophisticated software packages to support their IC activities. Less than 20% of the facilities had integrated radiology, diagnostic laboratory, or microbiology data with their facility computer system. The Internet was used primarily as a reference tool (77.4%). Most IPs reported taking responsibility for routine surveillance and monitoring tasks, but a substantial number did not perform all queried tasks. They may have difficulty with feedback of specific unit and physician infection rates (43.2% and 67.7%, respectively).

CONCLUSIONS

Our findings underscore what has previously been reported about LTCFs' IC human resources and IP scope of practice. We also found that some IT infrastructure was outdated, and that existing resources were underutilized for IC purposes.

Nursing home deficiency citations for infection control

BACKGROUND

This study examined the deficiency citation for infection control (ie, F-Tag 441). This information represents potential problems in infection control as identified in the yearly certification process of almost all US nursing homes.

METHODS

The data used came primarily from the Online Survey, Certification, and Reporting data base, which contains information on both deficiency citations and characteristics of nursing homes. The data for each nursing home from 2000 through 2007 were combined, providing a panel of 100,000 observations. Multivariate analyses and generalized estimating equations with a logit link were used.

RESULTS

An average of 15% of all nursing homes received a deficiency citation for infection control each year from 2000 to 2007. In the multivariate analyses, several staffing levels were robust in their significance. For all 3 types of caregiver examined (ie, nurse aides, Licensed Practical Nurses, and Registered Nurses), low staffing levels were associated with receipt of a deficiency citation for infection control.

CONCLUSION

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.

Infection Control and the Long-Term Care Facility

Approximately 70% of health care associated pathogens are resistant to one or more antibiotics. Experts maintain that most antimicrobial-resistant pathogens develop from antibiotic overuse and inappropriate antibiotic selection or treatment duration. Up to 70% of long-term care residents receive at least one course of an antimicrobial agent during a one-year period. Four types of infections occur most often among long-term care residents: urinary tract, respiratory tract, skin and soft tissue, and gastrointestinal tract, and outbreaks are common. Diagnostic uncertainty, failure to recognize fever's clinical manifestation in the elderly, treatment of asymptomatic bacteriuria, and bacterial colonization contribute to antibiotic overuse. Recent infection control guidelines recommend more targeted antibiotic utilization review. Recommendations are presented for implementing antibiotic utilization programs. Hand washing and other measures, such as droplet precautions, are discussed. Economic disincentives surrounding antimicrobial research are highlighted.

Indwelling device use and antibiotic resistance in nursing homes: identifying a high-risk group

OBJECTIVES

To quantify the relationship between indwelling devices (urinary catheters, feeding tubes, and peripherally inserted central catheters) and carriage of antimicrobial-resistant pathogens in nursing home residents.

DESIGN

Cross-sectional.

SETTING

Community nursing home in Southeast Michigan.

PARTICIPANTS

Residents with indwelling devices (n=100) and randomly selected control residents (n=100) in 14 nursing homes.

MEASUREMENTS

Data on age, functional status, and Charlson comorbidity score were collected. Samples were obtained from nares, oropharynx, groin, wounds, perianal area, and enteral feeding tube site. Standard microbiological methods were used to identify methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CTZ-R) gram-negative bacteria (GNB).

RESULTS

Use of indwelling devices was associated with colonization with MRSA at any site (odds ratio (OR)=2.0, P=.04), groin (OR=4.8, P=.006), and perianal area (OR=3.6, P=.01) and CTZ-R GNB at any site (OR=5.6, P=.003). Use of enteral feeding tubes was associated with MRSA colonization in the oropharynx (OR=3.3, P=.02).

CONCLUSION

Use of indwelling devices is associated with greater colonization with antimicrobial-resistant pathogens. This study serves as an initial step in defining a high-risk group that merits intensive infection control efforts.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Preventing infections in nursing homes: a survey of infection control practices in southeast Michigan

BACKGROUND

Studies on adherence to infection control policies in nursing homes (NHs) are limited. This pilot study explores the use of various infection control practices and the role of infection control practitioners in southeast Michigan NHs.

METHODS

A 43-item self-administered questionnaire and explanatory cover letter were mailed to 105 licensed NHs in southeast Michigan. A second mailing was sent to the nonresponders 4 weeks later.

RESULTS

Significant variability existed in adoption of various infection control measures with respect to time spent in infection control activities (50% of facilities having a full-time infection control practitioner), definitions used in monitoring infections, and immunization rates (influenza: range, 0%-100%; mean, 73.2%; pneumococcal: range, 0%-100%; mean, 38.5%).

CONCLUSION

Although strides have been made in infection control research in NHs, significant variations exist in implementation of infection control methods and guidelines. Future research should focus on identifying barriers to infection control in NHs.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Disruption of ergosterol biosynthesis confers resistance to amphotericin B in Candida lusitaniae

Candida lusitaniae is an emerging human pathogen that, unlike other fungal pathogens, frequently develops resistance to the commonly used antifungal agent amphotericin B. Amphotericin B is a member of the polyene class of antifungal drugs, which impair fungal cell membrane integrity. Here we analyzed mechanisms contributing to amphotericin B resistance in C. lusitaniae. Sensitivity to polyenes in the related fungi Saccharomyces cerevisiae and Candida albicans requires the ergosterol biosynthetic gene ERG6. In an effort to understand the mechanisms contributing to amphotericin B resistance in C. lusitaniae, we isolated the ERG6 gene and created a C. lusitaniae erg6 delta strain. This mutant strain exhibited a growth defect, was resistant to amphotericin B, and was hypersensitive to other sterol inhibitors. Based on the similarities between the phenotypes of the erg6 delta mutant and clinical isolates of C. lusitaniae resistant to amphotericin B, we analyzed ERG6 expression levels and ergosterol content in multiple clinical isolates. C. lusitaniae amphotericin B-resistant isolates were found to have increased levels of ERG6 transcript as well as reduced ergosterol content. These changes suggest that another gene in the ergosterol biosynthetic pathway could be mutated or misregulated. Further transcript analysis showed that expression of the ERG3 gene, which encodes C-5 sterol desaturase, was reduced in two amphotericin B-resistant isolates. Our findings reveal that mutation or altered expression of ergosterol biosynthetic genes can result in resistance to amphotericin B in C. lusitaniae.

Interactions among strategies associated with bacterial infection: pathogenicity, epidemicity, and antibiotic resistance

Infections have been the major cause of disease throughout the history of human populations. With the introduction of antibiotics, it was thought that this problem should disappear. However, bacteria have been able to evolve to become antibiotic resistant. Nowadays, a proficient pathogen must be virulent, epidemic, and resistant to antibiotics. Analysis of the interplay among these features of bacterial populations is needed to predict the future of infectious diseases. In this regard, we have reviewed the genetic linkage of antibiotic resistance and bacterial virulence in the same genetic determinants as well as the cross talk between antibiotic resistance and virulence regulatory circuits with the aim of understanding the effect of acquisition of resistance on bacterial virulence. We also discuss the possibility that antibiotic resistance and bacterial virulence might prevail as linked phenotypes in the future. The novel situation brought about by the worldwide use of antibiotics is undoubtedly changing bacterial populations. These changes might alter the properties of not only bacterial pathogens, but also the normal host microbiota. The evolutionary consequences of the release of antibiotics into the environment are largely unknown, but most probably restoration of the microbiota from the preantibiotic era is beyond our current abilities.

Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel

The number of frail, older residents of long-term care facilities (LTCFs) will increase dramatically over the next 30 years. Improving the quality of health care provided in LTCFs is an important national and international priority. Improving the prevention and management of infections in LTCFs is a critical component of efforts to improve quality of care and poses unique challenges. This report summarizes the presentations and discussions of participants in an invitational conference to propose a research agenda for prevention and management of infections in LTCFs. The conference was held in March 2001 in Atlanta, Georgia. The discussants identified key research questions to better understand general issues involving the overall burden of infections in LTCFs, prevention and control interventions, and antimicrobial use and resistance. The participants also discussed research questions involving specific infections, including pneumonia and urinary tract, skin, and soft tissue infections. Recommendations for research were discussed and are presented in summary form in this report. Improving the prevention and management of infections in LTCF residents should be a priority if quality of care in these facilities is to be improved. Many unanswered questions remain in this field, and the research agenda outlined in this report will require resources and focus. The benefit of such efforts to LTCF residents and their caregivers is likely to be substantial.

The role of the laboratory in infection prevention and control programs in long-term-care facilities for the elderly

Hospital infection prevention and control programs rely extensively on diagnostic microbiology laboratory testing. However, specimens for microbiological evaluation are less likely to be obtained from elderly residents of long-term-care facilities (LTCFs). In this article, issues regarding laboratory utilization and the potential role of the microbiology laboratory in infection prevention and control programs in LTCFs are reviewed. The role of the laboratory in infection surveillance, in the management of antimicrobial resistance, and in outbreak investigation are highlighted.

Hospital bloodborne pathogens programs: program characteristics and blood and body fluid exposure rates

OBJECTIVE

To describe hospital practices and policies relating to bloodborne pathogens and current rates of occupational exposure among healthcare workers.

PARTICIPANTS AND METHODS

Hospitals in Iowa and Virginia were surveyed in 1996 and 1997 about Standard Precautions training programs and compliance. The primary outcome measures were rates of percutaneous injuries and mucocutaneous exposures.

RESULTS

153 (64%) of 240 hospitals responded. New employee training was offered no more than twice per year by nearly one third. Most (79%-80%) facilities monitored compliance of nurses, housekeepers, and laboratory technicians; physicians rarely were trained or monitored. Implementation of needlestick prevention devices was the most common action taken to decrease sharps injuries. Over one half of hospitals used needleless intravenous systems; larger hospitals used these significantly more often. Protected devices for phlebotomy or intravenous placement were purchased by only one third. Most (89% of large and 80% of small) hospitals met the recommended infection control personnel-to-bed ratio of 1:250. Eleven percent did not have access to postexposure care during all working hours. Percutaneous injury surveillance relied on incident reports (99% of facilities) and employee health records (61%). The annual reported percutaneous injury incidence rate from 106 hospitals was 5.3 injuries per 100 personnel. Compared to single tertiary-referral institution rates determined more than 5 years previously, current injury rates remain elevated in community hospitals.

CONCLUSIONS

Healthcare institutions need to commit sufficient resources to Standard Precautions training and monitoring and to infection control programs to meet the needs of all workers, including physicians. Healthcare workers clearly remain at risk for injury. Further effective interventions are needed for employee training, improving adherence, and providing needlestick prevention devices.

Emerging health care-associated infections in the geriatric population

The increasing number of persons >65 years of age form a special population at risk for nosocomial and other health care-associated infections. The vulnerability of this age group is related to impaired host defenses such as diminished cell-mediated immunity. Lifestyle considerations, e.g., travel and living arrangements, and residence in nursing homes, can further complicate the clinical picture. The magnitude and diversity of health care-associated infections in the aging population are generating new arenas for prevention and control efforts.

Preventing infections in non-hospital settings: long-term care

Infection concerns in long-term care facilities include endemic infections, outbreaks, and colonization and infection with antimicrobial-drug resistant microorganisms. Infection control programs are now used in most long-term care facilities, but their impact on infections has not been rigorously evaluated. Preventive strategies need to address the changing complexity of care in these facilities, e.g., the increased use of invasive devices. The anticipated increase in the elderly population in the next several decades makes prevention of infection in long-term care facilities a priority.

Hospital-acquired infections in Norwegian long-term-care institutions. A three-year survey of hospital-acquired infections and antibiotic treatment in nursing/residential homes, including 4500 residents in Oslo

Point prevalence studies of hospital-acquired infections among the elderly in 65-70 long-term care facilities (LTCF) were carried out once a year over a three-year period in Oslo city, Norway. They showed an overall rate of 6.5% of hospital-acquired infections among 13 762 residents. The infection rate was approximately the same as in hospitals and twice as high as among hospitalized long-term psychiatric patients. Residents who had received surgical treatment within the previous three months had a high rate of postoperative infections, especially wound infections (14.8%). During the study period, the LTCFs were found to be understaffed and overcrowded. They had few private rooms, a lack of bathrooms and toilets, no isolation facilities and deficient ventilation systems. The economic consequences of hospital-acquired infections in these LTCFs were extra costs in medical and nursing care and antibacterial treatment of 157 500 Nkr/day (22500 USD). There would be a substantial cost-benefit in effective preventive measures against hospital-acquired infections in long-term care institutions.

Infection control in long-term care facilities

Infections are common in long-term care facilities. The most frequent endemic infections are urinary infection, respiratory infection, and skin and soft tissue infections. Outbreaks also occur frequently, and some facilities have a high prevalence of colonization of residents with antimicrobial-resistant organisms. Our understanding of infections and the development of infection-control programs for long-term care facilities have progressed greatly over the past 15 years. Whereas the occurrence of infections has been described and specific guidelines for infection-control programs in long-term care facilities have been developed, there is still limited evaluation of the effectiveness of programs or specific interventions to support prioritization of infection-control resources. In addition, the spectrum of patients and care delivered in long-term care facilities continues to evolve. Increasingly, chronic care patients, including those requiring chronic respirator therapy, dialysis, or percutaneous feeding tubes, are cared for in these facilities. Our understanding of prevention of infection in these patients remains limited. Important questions include what interventions may prevent endemic infections, what are the most effective means to identify outbreaks early, and what interventions may minimize the prevalence of antimicrobial-resistant organisms. Programs to optimize antimicrobial use need to be developed. Thus, although progress in understanding and practice has been made, important questions remain.

Infection control programs in long-term-care facilities: structure and process

Due to the rapid transfer of patients from the acute-care setting, the intensity of nursing care among residents in long-term-care facilities (LTCFs) has increased, transforming today's LTCFs into subacute healthcare facilities. Given the increased risk of infection among residents in LTCFs and the associated morbidity and mortality, evaluation of infection control programs in skilled nursing LTCFs is warranted. This article addresses the current structure and process of infection control programs in skilled nursing LTCFs.