Cleaning up infection control

Although limited data have been gathered on national infection rates within skilled nursing, the Centers for Disease Control and Prevention (CDC) estimates the long-term care (LTC) setting sees 1.6 million to 3.8 million healthcare-associated infections (HAIs) annually, making HAIs one of the top 10 causes of death in the United States. Clostridium difficile has garnered the most attention in the recent past, but the rates of other infections continue to be closely monitored including Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), said Phenelle Segal, RN, CIC, a national expert on infection control and prevention within LTC environments, in a recent Long-Term Living webinar.

HAIs play a role in 30 percent to 50 percent of hospital transfers involving long-term care and add more than a billion dollars in additional costs to the U.S. healthcare system, Segal noted. More importantly, HAIs result in at least 100,000 resident deaths per year. When was the last time you examined your facility’s cleaning and disinfection protocols and products?

Most common HAIs in LTC

  • Urinary tract infection
  • Respiratory tract infection
  • GI tract infection (norovirus, Clostridium difficile)
  • Influenza
  • Skin and soft tissue infection
  • Bacteremia

The Centers for Medicare & Medicaid Services (CMS) drew the official line in the sand in 2012, initiating reimbursement reductions for hospitals that failed to reduce HAIs by set increments, a move that provided prime ground for acute care and LTC sites to work together to combat preventable infection rates. But combatting HAIs that are multidrug resistant and are easily spread in the community-based settings of long-term care isn’t easy.

A national action plan had been in the works since 2008 to form a roadmap to the elimination of preventable infections, a task force that Segal was part of. Pennsylvania became a leading state in the LTC initiative and remains one of the few states that now requires reporting on HAIs in LTC settings.

The best practice protocols to curb multidrug resistant organisms (MDROs) in LTC’s communal setting involve environmental cleaning, clinical caregiver and social aspects. Everyone who comes into contact with an infected resident or that resident’s living space needs to be included in the team-based approach to infection control—including housekeeping, dining services personnel, clinicians, social workers and others. The best option for prevention of transmission of MDROs is to place the resident on isolation precautions, including contact precautions, preferably in a private room—an option that acute care often can enact, but an option that can be very difficult in LTC settings due to lack of private rooms as well as LTC settings acting as “home” for residents,  Segal noted.


Bed rails, call-buttons, door handles, toilet flush handles…. Most skilled housekeeping staffers are trained to disinfect the “high-touch, high-traffic” spaces and items and are accustomed to giving them the most attention when cleaning. Unfortunately, solely following the “high-touch, high-traffic” cleaning mantra isn’t enough these days, Segal explained.

The most significant risk to acute and long term care is the newer MDRO group known as carbapenem-resistant Enterobacteriaceae (CRE), since these organisms are resistant to roughly 99 percent of antibiotics used on a day-to-day basis, she added.

Cleaning products differ widely, with each product having its own directives for proper use. Many surface-applied cleaning products require a specific “standing time” before wiping away to kill pathogens. And any microbes that remain will only lead to a stronger pathogen pool (and more drug resistance) later.

No housekeeping regimen will succeed if caregivers don’t adhere to strict protocols concerning infected residents, Segal added. “We still have some issues with hand hygiene, so we have to stay diligent on that front,” she said. At a minimum, every caregiver should maintain proper hand-hygiene protocols when encountering an infected resident and should wear a gown and gloves, discarding both cover items every time he or she exits the resident’s room, to avoid spreading the microbes to others, she suggested.

“You must do your best to keep residents separated who have uncontrolled secretions,” she added.  “And please don’t ever put a resident with C. diff with a resident with another MDRO, because it’ll be a nightmare. Don’t mix MDROs.”


The best facility disinfection protocols are monitored and reviewed by key personnel, including administrators, on a regular basis—quarterly, at minimum—just to ensure that everyone is "on board" with the current infection control strategies. Much of the infection control plan involves housekeeping and the products the housekeeping team uses to keep your facility’s surfaces and spaces free of spreadable germs.

Traditional disinfection products range from surface sprays to wipes. Many of these products fall into the following categories:

  • Bleach (sodium hypochlorite), used in varying strengths for different, specified uses;
  • Quaternary ammonium compounds (“quats”), with or without isopropryl alcohol; and
  • Phenolics (rarely used now, Segal noted).

Several new technologies have been introduced to the market in recent years that can add to an LTC facility’s armory of infection control. Many of the newer technologies can be used on soft or porous surfaces as well as hard surfaces. Make sure the product is Environmental Protection Afgency (EPA)-registered before considering it for your facility, Segal noted. Some of the newer EPA-registered cleaning products:

  • Hydrogen peroxide-based (usually 0.5%) sprays and wipes;
  • Chlorine dioxide + alkyl-dimethyl-benzyl ammonium chloride; and
  • Products that combine silver, acetic acid, ethanol and hydrogen peroxide.

An additional category of new technology is embracing “whole room” delivery modes, using microscopic vapor to ensure better coverage, including in corners and underlying areas. Among these technologies:

  • Air-assisted electrostatic sprayers, using EPA-registered chemicals;
  • Portable ultraviolet units; and
  • Portable hydrogen peroxide vaporizing units.

“The disinfection/germicide products we most often use in high-risk areas are quats, in either sprays or wipes, or else bleach, particularly to eliminate C. difficile and norovirus. But the newer disinfection technologies are exciting. We now have safer, more environmental-friendly products that are EPA-registered, noncorrosive to the skin and eyes, and can be used in kitchens and on carpets.”


Regardless of your facility’s current cleaning regimen, it’s crucial to monitor housekeeping’s processes and install protocols for working within the spaces where residents with infections reside. Don’t assume the more stringent protocols will happen by themselves, even among clinical staff, Segal noted.

Clinicians and caregivers also need to be updated on the increased scrutiny on infection transfer-risk, Segal said: “Even if someone is going into the room just to adjust the IV and not touching the resident, [he or she] need[s] to have a new gown and gloves on, and ensure hand hygiene. The surveyors will be looking for those preventive measures.”



Topics: Articles , Risk Management