Infection Controlin Long-Term Care

Cooperation, planning,and much detectivework form the basisof every good program.

MARY CARROLL

Recent changes in government reg­ulations for infection control haveaffected the accountability of long­term care institutions. Regulationsoriginate from various agencies andaccrediting bodies at federal, state,local, and professional levels.

Nurses, to whom responsibilityfor infection control usually falls,are faced with countless rules andrequirements. Furthermore thepublished guidelines on preventinginstitutionally acquired (nosocomi­al) infection, or controlling thetransmission of infections from res­idents admitted with them, oftenseem more relevant to acute carefacilities.

But the problems that plagueboth acute and long-term care arethe same. And the principles of in­fection control are the same. Onlythe population at risk is different.

Many institutionalized elders aremore susceptible to infection thanyounger persons. Some age-relatedchanges predispose the aged to de­velop infection. To complicate mat­ters, it is not always easy to recog­nize signs of infection if the individ-

Mary Carroll, RN, MA (Gerontology). is apartner and co-owner of Outreach NursingService, Fairbury, IL. Formerly a staffnurse and inservicc director, she has hadeight years' experience with infection con­trol in acute or long-term care facilities.

100 Geriatric Nursing March/April 1984

ual's sensorium is blurred or if ho­meostasis is compromised.

Although mortality figures indi­cate that cardiovascular diseasesare the leading cause of deathamong the elderly, infectious pro­cesses such as pneumonia, cystitis,and septicemia are often contribut­ing factors(l).

An infection control committeecan assume responsibility for thedevelopment of a workable' infec­tion control program. A nursemember assists with policy devel­opment as well as surveillance ac­tivities, but responsibility for theprogram does not lie solely with thenursing department. Infection con­trol is a continuing daily obligationof all departments and employeeswhatever level of care the facility islicensed to provide.

Since the program's success de­pends on cooperation among manydisciplines, the infection controlcommittee includes respresenta­tives from housekeeping, mainte­nance, dietary, and laundry ser­vices as well as medical, nursing,pharmacy, and administrative per­sonnel.

Committee Functions

How often the committee meetsdepends on what the group mustaccomplish and on the licensureand accreditation requirements tobe met. The infection control meet­ing is held separately from othercommittee meetings to avoid dilu­tion of purpose and interest. Awell-prepared agenda can saveeveryone's time.

The committee's first order ofbusiness is to formulate the facili-

ty's infection control policies andprocedures and present them in amanual. This may seem like a bur­densome undertaking, but' a well­designed manual is the cornerstoneof an effective program. .

No one person can construct themanual. All departments involvetheir members in the creation ofpolicies and procedures. The veryact of preparing the manual can in­crease awareness of potential prob­lem areas.

Three excellent guides for poli­cyjprocf'rlure development andmanu., '.~"lnization are "InfectionControl 11. Extended Care Facili­ties," "The APIC Starter Kit," and"A Departmental Guide for Infec­tion Control Programs"(2-4).

The committee reviews and ap­proves policies and procedures an­nually, looking closely at areas ofresponsibility to ensure that theseare dearly delineated. For exam­ple, if housekeeping is responsiblefor cleaning the kitchen, dietary isresponsible for cleaning the em­ployee's dining room, and nursingis responsible for cleaning resi­dents' equipment and wheelchairs,this should be stated in the manual.The committee may change orreassign these responsibilities tomake the program more time andcost effective.

Departments of public health canoften provide consultants and infor­mation resources to infection con­trol committees. Their personnelare particularly helpful when thecommittee is interpreting new reg­ulations.

Another task is to define infec­tion in operational terms. "Outline

THE DELAyeD PHYSICAL EXAM• Mr. A. was hired to fill a vacancy in the housekeeping department of along-term care facility. He'd been laid off by the factory where he had beenemployed for many years. Car trouble prevented him from keeping the ap­pointment for his preemployment physical, but he was allowed to start workafter promising to reschedule his appointment..He failed to do so.

A month later tuberculin skin testing was conducted throughout the facility.Mr. A.'s test was positive and follow-up examination revealed active tuber­culosis. Fortunately, Mr. A did not work in direct contact with residents, andno co-workers became infected or demonstrated positive skin tests. Surveil­lance is continuing, however.

The infection control nurse alerted local health department officials, whosecured medical care for Mr. A. and his family, taught them how to deal withhis disease, and screened employees at the factory where he hadworked.

An inservice program, conducted by the American Lung Association, washeld at the long-term care facility to acquaint all employees with currentfacts about tuberculosis and to allay fears. The infection control nurse andinservice director placed a bulletin board near the employees' time clockwith information and take-home pamphlets on tuberculosis. Positive em­ployee response encouraged them to feature a different disease eachmonth.

This situation would not have occurred if the established policy of preem­ployment health screening had been followed. This single lapse potentiallythreatened the health of the entire community as well as residents and staffof one facility.

for Surveillance and Control ofNosocomial Infections" can guidethe establishment of criteria for de­termining whether infection is pres­ent(S).

The criteria must be applicableto the facility. For example, infec­tion may be diagnosed on the basisof physical assessment alone ifthere is an inevitable delay in ob­taining diagnostic data because thefacility is located far from a labora­tory or X-ray department. There­fore, subjective and objective crite­ria are developed, and empiricaldata included. Dysuria and pyuria,for instance, may be criteria for di­agnosing urinary tract infection;pleuritic pain, cough, and purulentsputum the criteria for identifyinglower respiratory infection.

Diagnosis-related group reim­bursementunder Medicare may re­sult in extended care agencies en­countering applicants whose totalhealth histories have not beenscreened. Hence particular atten­tion to possible subclinical infectionis important.

The committee develops policiesgoverning the admission of resi­dents with known infections. Suchpolicies must meet public healthand licensure standards, and somust treatment policies. The com­mittee considers the personnelavailable, the equipment, and envi­ronmental requirements when con­sidering the admission and care ofelders who have infections.

Preadmission diagnostic andscreening tests are clearly stated inthe manual. For example, if an ap­plicant has a positive tuberculintest, a chest film and sputum testare done before admission is agreedto, in order to determine whetheractive tuberculosis is present. If thefacility cannot provide the neces­sary care and treatment because ofphysical or staff limitations, the ad­mission policies should reflect this.The transfer of residents who ac­quire infections calls for still anoth­er policy.

Procedures that cover isolation,enteric precautions, and so forthare spelled out in detail. "IsolationTechniques for Use in Hospitals" isan informative reference(6).

Employee health policies arewritten to assure that health re­quirements conforming to govern­mental and institutional standardsare met before employment (seeThe Delayed Physical Exam). Poli­cies related to annual physical ex­ams or health screening stipulateany necessary follow-up actionsand specify who arranges and whopays for such services.

The committee prepares guide­lines that identify the conditions

under which an employee is not al­lowed to work (for example, in­fluenza or staphylococcal infec­tion); conditions requiring that anemployee be assigned to functionsnot involving direct care (skin in­fections, severe colds); and the pro­cedure for determining when em­ployees may return to work.

If a nurse is responsible for man­aging the employee health pro­gram, medical protocols are devel­oped for administering immuniza­tion or performing invasive proce­dures, such as skin tests. The skintesting agent, contraindications forits administration, and manage­ment of side effects or anaphylacticreactions are described. Writtencriteria for the interpretation of

such invasive tests are essential.The committee defines its scope

of authority and responsibility.Procedures for reporting and deal­ing with problems are communi­cated in writing to all departments,and the person(s) responsible formaking decisions is identified.Among these are decisions to re­strict visitors to the facility duringa community or institutional epi­demic, to isolate an infected resi­dent, to collect cultures, and to se-

lect or purchase equipment andsupplies that .are necessary for in-fection control. .

Surveillance

The purpose of surveillance, thecommittee's other principal respon­sibility, is to identify infections, in­stitute preventive and controlmeasures, and evaluate the effec­tiveness of these measures. Meth­ods depend on the size of a facilityand the time a surveyor, usually theinfection control nurse, has avail­able. It is important that the ad­ministration support surveillanceand budget for sufficient staff andtime. Ideally; only one or two staffmembers act as surveyors in orderto maintain a consistent interpreta-

Geriatric Nursing March/April 1984101

• Within two days, seven staff members developed upper respiratory infec­tions that kept them from working. All were treated by their private physi­cians; no throat cultures were taken.

Because this represented an unusually high incidence of URI, the infectioncontrol nurse began an investigation.

The affected staff worked on different units, but all had attended a reviewsession on cardiopulmonary resuscitation three days before their illness.The infection control nurse cultured the airway of the mannequin used forpractice; Staphylococcus aureus was present. Cultures were not done onany employees present at the session.

Further investigation revealed that the mannequin had not been disinfectedfor a long time, contrary to facility policy. Although the staff members' res­piratory infections could have originated from another source, the mannequinseemed the most likely reservoir of infection.

• Ms. B., an 80-year-old resident of a long-term care facility, retired at 8:00PM after attending a family reunion. Several hours later she developed lowgrade fever, abdominal cramps, and diarrhea. After careful assessment, astaff nurse instituted enteric precautions and saved a stool specimen forculture.

Two days later Ms. B:s daughter telephoned the director of nursing toreport that several family members had become ill. Salmonella were subse­quently detected in their stool cultures. Presumably the pathogens had beenpresent in food eaten at the family party.

Ms. B:s gastrointestinal symptoms gradually abated following antibiotictherapy, and her original and successive stool cultures contained only non­pathogenic organisms. If Salmonella had been present, however, the entericprecautions promptly started by an astute nurse could have prevented anoutbreak of infection among both residents and staff.

PRUDENT PRECAUTIONS

THE CONTAGIOUS MANNEQUIN

attack rate. Although some infec­tions may be overlooked when thepoint prevalence study is used, thismethod takes less time and freesthe surveyor for other activities.

The prevalence/incidence studyis accomplished by collecting dataover time, usually a month. Thesurveyor visits nursing units dailyor relies on other nurses to recorddata. The total number of infec­tions is entered in a monthly report.Although this study is more timeconsuming, it is another valuabletool, especially for the investigationof clusters of infection (see TheContagious Mannequin).

Residents at special risk, such asthose with indwelling urinary cath­eters or decubitus ulcers, are sur­veyed daily.

Incidence studies can identifywhether problems exist in only oneunit or throughout the facility. Theneed for control measures can alsobe demonstrated. A graphic displayof the prevalence rate for a nursingunit or the whole facility can stim­ulate staff awareness of infectioncontrol problems.

If there is increasing evidence ofurinary tract infections, the infec­tion control nurse would reviewcatheterization procedures, cathe­ter care, and urine sampling tech­nique with all staff. After studyingthe data, the committee might de­cide to change the type of equip­ment used or revise procedures.

Various methods exist for calcu­lating the attack rate of infections.Attack rate can be calculated for

The infection control nurse mayexperiment with different surveil­lance methods to decide which iseasiest to use and yields the mostinformation. It is important thatthe method chosen be used consis­tently throughout the facility.

Study Methods

The collection of baseline data isan example of a prevalence/inci­dence study. A point prevalencestudy is one that takes place at adesignated time, usually one day amonth, or one day every threemonths. On that day all charts areaudited for evidence of infectionand the residents are visited by thesurveyor, if possible, to look for in­fections which have not yet beendocumented. If the facility is large,it is usually necessary to survey onenursing unit at a time.

The information collected on thegiven day is used to determine the

tion of the findings.Collection of baseline data on in­

fections already present is the firststep. Each resident is evaluated bydirect inspection, preferably on ad­mission, and at regular intervalsthereafter. Carrying a list of thecriteria for infections is useful for anovice surveyor. All sources of in­formation are tapped-residents'charts with their laboratory re­ports, vital sign records, and flowsheets are obvious places to look.

A good time to observe residentsand informally confer with staffmembers is during the nursing careplanning conference. This is also anexcellent opportunity to provide in­stant teaching on infection controland to contribute to nursing plansfor the care of any residents whoevidence infection.

Baseline surveillance data in­clude the resident's name or iden­tifying number, location, attendingphysician, site of infection, date ac­quired, known pathogens, and pos­sible factors that predispose thisresident to develop infection.Among these factors are indwellingcatheters, intravenous lines, immu­nosuppressant therapy, tissue trau­ma, chronic lung disease, malnutri­tion, and immobility.

With baseline data recorded foreach resident, the surveyor can eas­ily detect a.inosocomial infectionand institute control measures,such as wearing gloves when givingdirect care; needle, stool, or dishprecautions; and other measures toprevent infecting others (see Pru­dent Precautions, above).

102 Geriatric Nursing March/April 1984

individual nursing units or an en­tire facility. The method most fre­quently used is to divide the num­ber of infections by the number ofresidents, then multiply by 100 toexpress the rate as a percentage.Again, the method selected is thenused consistently.

Evaluation

Assessment of the results of aninfection control program is essen­tial; many accrediting bodies re­quire it .

If medical care evaluations areundertaken by the facility, thesehelp provide evidence. Useful stud­ies could include investigations ofphlebitis associated with the use ofsteel needles versus catheters forintravenous therapy, the manage­ment of decubitus ulcers, the inci­dence of nosocomial respiratory in­fection, and so forth .

Repeated cultures of housekeep-

ing or laundry equipment are notnecessary to evaluate the effective­ness of cleaning procedures unlesssuch culturing is stipulated by gov­ernment regulations. Instead, com­mittee members can evaluatecleaning and laundry procedures bymaking periodic inspections anddocumenting their findings in thecommittee minutes.

However, if hydrotherapy or res­piratory therapy equipment is inuse, microbiological sampling "is­done regularly (seeThe ContagiousMannequin). Procedures for steamautoclaving or other types of steril­ization must comply with pertinentregulations. Usually these requireweekly chemical and/or biologicalmonitoring of such equipment. Thewater temperatures for dishwash­ing and laundering are also docu­mented in the minutes.

While regulations may vary withtime and place, the prevention of

infections is a consistent theme inlong-term care. Persistent attentionto this activity will protect those atgreatest risk, the residents, as wellas their caregivers.

ReferencesI. Weg, R. B. Changing physiology of the aged:

normal and pathological. IN Health AspectsofAging, ed, by G. D. M. Burdman and R. M.Brewer. Portland,Ore.• Con tinuing EducationPublications, 1978, p. 26.

2. Beckwith. D. G., and Sal venti, J . F., eds, In­fection Control in Extended Care Facil it ies;Proceedings of the Microbiology Sympo­sium-March 22, 1979. Allentown, Pa ., Al­lentown-Sacred Heart Hospital Center,1980.

3. Association for Practitioners in InfectionControl. Starter Kit. Halfway, 111., (R. 2),The Association , 1978. -

4. Craig, C. P.• and Risesynder, D. N.A Depart­mental Guide for Infection Control Pro­grams. Oradell, N.J ., Medical EconomicsCo., 1975.

5. U. S . Centers for Disease Control. Outline forSurveillance and Control of Nosocomial In­fect ions . Atlanta, Ga .• The Centers. 1974.

6. Isola tion Techniques for Usein Hospitals, Atlanta, Ga. . The Cent ers,1975.

PHYLLIS ·W ILLIAMSBETTY BIERER

Phytlis Williams, PhD, SM(Epidemiology),is an associa te professor at Kent State Uni­versity, Kent, OH. Betty Bierer, RN, BS(Public Administration), is infection con­trol nurse and inservice coordinator atRochester-United Methodist Home, Roch­ester, NY.

Nurses and doctors all know thathospital-acquired infections are alarge problem and that frequent,thorough hand washing is a largepart of the solution. Think abouttoday, were you a part of the prob­lem or the solution? Be honest! Ifyour pay depended on followingcorrect hand washing procedure,how big would your last check havebeen?

If you came up a little (or a lot)short, it appears that you wouldhave a lot of company. Albert's andCondie's 1981 studies of handwashing by health care profession- .

Wash Your Hands!

als found that in an ICU of a uni- ­versity-affiliated -hospital, physi­cians washed their hands following28 percent of contacts compared to43 percent for nurses. In a privatehospital the percentages were 14percent and 28 percent for physi­cians and nurses respectively(1).When asked why physicians don'talways wash their hands, Albertsuggested that it was because mostpatients aren't "obviously" in­fected(2). Even though this studywas conducted in acute care hospi­tals, is there any reason to believethat things are better in long-termcare facilities?

What accounts for such laxity onthe part of those who care for the

______________ sick? Is-it lack of training? Hardly..We all had the importance of handwashing drilled into us. Certainlyit's not for lack of admonitions inthe literature that "good handwashing practices are at the heartof infection control"(3) .

A few years ago Johns HopkinsUniversity Hospital cut urinarytract infections in half simply byhaving infection control staff "goover to the ward and get doctors,nurses, and aides to do what theyalready knew they should do, suchas washing their hands afteremptying . a patient's catheterbag"(4). Experts may disagreeabout which agents should be usedand under what circumstances; noone disagrees about the importanceof hand washing.

Under some circumstances itdoes take a conscious effort to re- .member to wash. Consider thenurse who is caring for one patientin a two-bed room and the other pa­tient demands a drink right now. Inhaste to keep peace , the nurse com­plies without taking time to washher hands. Or the physician with aslight, nonproductive cough that"really isn't much" who remem­bers to cover his mouth but forgets

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