AMDA-Dedicated to Long Term Care Medicine (formerly the American Medical Directors Association) recently updated its “Common Infections in the Long-Term Care Setting Clinical Practice Guideline.”1 Survey organizations consider these guidelines to be a source of authoritative guidance (as well as evidence-based and expert-endorsed) for LTC practitioners and the interdisciplinary team. A more comprehensive discussion on infection prevention and control is available in that publication and a summary is available at the National Guideline Clearinghouse (www.guideline.gov). Electronic or hard copies of the guideline are available from AMDA for a fee.
TRANSMISSION OF INFECTION
Staff, residents and family members need to realize that communal living and consequent “hands-on,” close-contact care facilitates explosive outbreaks of viral pathogens that also sicken staff (norovirus, influenza and other potentially lethal respiratory viruses). This situation also leads to the more gradual transmission of Multidrug-resistant Organisms (MDRO) including Methicillin-resistant Staphylococcus aureus (MRSA) and quinolone-resistant gram-negative bacteria.
Explosive outbreaks require rapid identification and establishment of control measures that, unfortunately, limit resident activities. Clinical outbreaks of gastrointestinal or respiratory illness may manifest on nights or weekends. Weekly tabulation of new cases by the infection preventionist might not always adequately identify explosive outbreaks with high attack rates. Therefore, frontline staff should be trained to rapidly identify these situations, initiate a line listing and report to supervisors. The early application of isolation precautions is a crucial step in containment.
AMDA-Dedicated to Long Term Care Medicine, the professional association of medical directors, attending physicians and others practicing in the long-term care continuum, is dedicated to excellence in patient care and provides education, advocacy, information and professional development to promote the delivery of quality long-term care medicine. For more information, go to www.AMDA.com.
Transmission may also present as a more extended clustering of MDRO/MRSA on a single nursing unit. The identification of clustering in “time and space” requires analysis of a clinical bacteriology database-something that many nursing facility staff may not be trained to analyze. According to the AMDA guideline, while LTC facilities have to maintain records of patients treated for infection, such records are of limited use for the prevention of infection. Aggregate data analysis that provides information about patterns of specific infections within the facility is much more useful. It is this type of analysis that can prompt the facility to modify and improve the control (and prevention) of infections.
Infection prevention is the responsibility of all staff. The infection prevention program should be embedded into all aspects of facility practice with efforts to minimizing effects on resident autonomy. The consistent application of hand hygiene is a cornerstone of prevention, which should be performed by staff between resident contacts and by or for residents when they leave their rooms. The use of alcohol-based hand hygiene products has been associated with lower rates of MRSA.
Facilities are required to prohibit employees with transmissible infectious diseases or infected skin lesions from having direct contact with residents and residents' food because staff can be the source of outbreaks and lethal resident illness. Implement active screening programs to identify infected staff and visitors, especially during community outbreaks of viral respiratory or gastrointestinal illness. This screening is a foremost component of programs to prevent the introduction of pandemic influenza and other infectious diseases into LTC facilities. In addition, staff should be trained to monitor themselves for signs and symptoms of transmissible infection and to exclude themselves from work, and/or report to employee health or nursing staff for further evaluation.
Standard precautions are the cornerstone of efforts to prevent transmission. Known MDRO carriers are only the “tip of the iceberg” of all carriers. In other words, any resident can be a carrier and as that possibility exists, the intensity of the standard precautions should be based on that possibility. The 2007 CDC [Centers for Disease Control and Prevention] Isolation Guideline recommends gloves (and possibly a gown appropriate to the task) for direct contact with potentially contaminated intact skin regardless of MDRO carrier status (p. 79).2 Residents with potentially contaminated intact skin include those with uncontained secretions or excretions, incontinence and/or poor or absent hygiene. The Isolation Guideline also recommends contact precautions in the presence of uncontained drainage from an abscess or pressure ulcer regardless of MDRO status (pps. 94, 106).2 In many facilities nursing assistants wear gloves/gowns when providing personal hygiene, toileting and incontinence care regardless of MDRO carrier status. These tasks may not only contaminate staff hands but also their forearms and torso.
Universal respiratory hygiene and cough etiquette are also standard. All infectious respiratory secretions should be contained with 3-6 foot “spatial separation,” tissues, or masks. Standard precautions are quite extensive.