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Protecting Residents From Foodborne Illnesses

June 1, 2006
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A dietary perspective on infection control by Jamie Stamey, RD, LDN, CFSP
BY JAMIE STAMEY, RD, LDN, CFSP Protecting residents from foodborne illnesses
A well-planned, formal foodservice and enteral feeding program can keep residents safe and prevent survey deficiencies Doesn't every resident deserve safe food and nourishment? Every year, 76 million people get sick in the United States as a result of foodborne pathogens and viruses; of this number, 5,000 die a preventable death.1 This problem is exacerbated by the global nature of our food supply, as foodservice providers in the United States obtain more products from outside our borders. A major foodborne illness outbreak in a long-term care (LTC) facility can be catastrophic to all involved. Not only does it jeopardize the health of residents, but it also can damage a facility's reputation, devalue the organization's stock, and cause community alarm.

Residents of LTC facilities tend to be more vulnerable to foodborne illnesses than the general population. This is because of (1) age-related changes in their gastric pH, (2) the overuse of antibiotics that kill beneficial bacteria normally present in the body that provide protection against harmful microorganisms, and (3) the weakening of their immune systems by diseases and conditions (e.g., AIDS, diabetes, liver disease, and malnutrition), as well as medications and treatments that destroy or suppress immune cells (e.g., chemotherapy and radiation therapy). In confined environments such as nursing homes and other LTC facilities where these vulnerable residents live, foodborne pathogens can spread easily. Residents eat the same food from the same kitchen, share food, eat food brought in by visitors, eat during activities and special events, and save food from mealtimes-all factors that allow the chain of infection to flourish.

While anyone can get sick from foodborne pathogens, 20% of the U.S. population (including the elderly) is even more susceptible to opportunistic pathogens than the general population.1 These "invaders" are more problematic for elderly nursing home residents because these individuals may become ill from exposure to a lower infective dose, and they may develop more severe symptoms or even die. In fact, according to FoodNet, the Centers for Disease Control and Prevention's Foodborne Diseases Active Surveillance Network (, fatality from foodborne illness among nursing home residents is 10 to 100 times greater than for the general population.

Food safety in the LTC setting is not exclusively the responsibility of foodservice professionals; it extends to all medical and nutrition therapy staff, as well, including nurses and physical/occupational therapists. For example, food safety is equally important when foods are used by therapists to evaluate swallowing, when food is eaten during social activities, and when it is prepared to assess activities-of-daily-living skills.

Foods to Avoid
To reduce the risks of foodborne illness, nursing home residents are advised not to eat the following foods:

  • Raw finfish and shellfish (e.g., sushi or oysters)
  • Hot dogs and luncheon or deli meats, unless reheated until steaming hot
  • Raw or unpasteurized milk or soft cheeses
  • Refrigerated pGtTs or meat spreads
  • Refrigerated smoked seafood, unless contained in a cooked dish
  • Raw, lightly cooked, or unpasteurized eggs (e.g., sunny-side up)
  • Raw or undercooked meat or poultry (e.g., a rare or medium hamburger)
  • Raw bean and seed sprouts
  • Unpasteurized/untreated fruit or vegetable juice

Enteral Feeding, Nutritional Supplements
Another variable that can create potentially hazardous food safety conditions in LTC settings is the misuse of enteral formulas and supplemental shakes. Enteral formulas, for example, must be handled properly to avoid potential hazards, including:

  • Dangers associated with pouring a new tube-feeding formula into the bedside administration set before emptying the previous product;
  • Touch contamination (from unwashed hands) associated with both open and closed systems; and
  • Dangers associated with prolonged hang times of products and administration sets.

HACCP Program for Food Safety
A formal program for promoting and maintaining food safety is essential to protecting residents and meeting regulatory requirements. A Hazard Analysis Critical Control Points (HACCP) program is an ideal, proactive approach to ensuring food safety (see sidebar, "The Seven HACCP Principles"). The good news for LTC facilities planning to implement an HACCP program is that they may be farther along in the process than they realize because many of its components are likely already in place.

HACCP program foundations. The overall goals of an HACCP program are twofold: to ensure the safety of food and nutrition products and to create a process for corrective action and continuous improvement. Before implementing an HACCP program, it is important to complete several foundational steps. Most likely, these foundations are already part of your facility's Standard Operating Procedures (SOPs) and Sanitation Standard Operating Procedures (SSOPs).

An important requirement of SOPs, SSOPs, and HACCP programs is having all procedures in writing-as required by state and federal regulatory agencies and by JCAHO)-and accurately documenting the execution of those procedures. This is the best way to ensure consistent training of employees regarding food-handling procedures and the only way to validate whether those procedures are working correctly. From a food safety standpoint, this includes areas such as: