Prepare to prevent infectious outbreaks

Jane Kirk, RN, MSN, CIC

Sherrie Dornberger, RN, CDONA, FACDONA

Have you ever been at a meeting or conference and overheard someone say, “We have 2.3 hours per week for an infection prevention/control nurse”? Is this what is happening at your facility?

Infection prevention programs can make or break a facility along with the staff that oversees it. If the program makes the mistake of trying to do too much, reinventing the wheel, or culturing every “perceived” dirty surface in the facility, it is not only overwhelming, but it may discover information that you, your medical staff and your facility were not anticipating. Instead of doing random cultures or searching for organisms “to do something about,” use the information that you have readily available at your fingertips, sometimes on the computer screen in front of you!

F-tag 441 requires that the facility has an Infection Control (IC) program. The IC program enhances the long-term care facility and its residents in many ways.


The risk assessment is the building block of an IC program because it identifies the factors that place residents and employees at risk for facility-acquired infections. The risk assessment also helps to determine what areas to focus on for surveillance and process improvement projects. It also highlights the need for prevention programs, such as an employee influenza vaccine program. Some accrediting bodies ask to see the IC Risk Assessment during survey, and presenting one provides strong evidence of an active IC program.

To get started on the risk assessment, remember no man (or woman) is an island. Teamwork is key. Plan a multidisciplinary meeting to get perceptions of what and where infection control risks are. Administrators, bedside nurses, unit nurse managers, therapists who are regularly at the facility, as well as the medical director should be included in this meeting. The goal is to have good representation of all disciplines that are employed at the facility and involved in resident care. Consider including the dietary manager as well as the maintenance and/or facility engineer.

Once the meeting is scheduled, prepare for it. Have an agenda with all the discussion items timed out so that the meeting time is used efficiently. Before the meeting, ask the attendees to review the previous year’s records for documentation of infection control problems. Were there any outbreaks or clusters of infection? What were the problems and issues related to infection control during the previous year? Was there a water problem? Was there a problem with the water in the whirlpool? Were there pest control issues? A simple risk assessment includes five components:

  • Look at the resident population. Are there characteristics that put them at risk for infections? For example, is it a rehab facility that experienced several post-op total knee/hip infections? Or is this a pediatric long-term care population? Were a large number of patients admitted from the hospital with multidrug resistant organisms (MDROS) such as methicillin-resistant staphylococcus aureus (MRSA) or vancomycin-resistant enterococcus (VRE)?

  • Look at the services provided such as ventilator support, physical therapy including whirlpool, IV therapy, hospice or dementia unit. Maybe the facility has an active population that goes into the local community often or has an intergeneration program for schoolchildren.

  • Look at the risks such as ventilator-associated pneumonia, antibiotic-associated diarrhea, peripheral inserted central catheter (PICC) line associated bloodstream infection and employee illnesses.

  • Look at risk level. Quantify the risks either by numbering them in order of severity or frequency of occurrence. Identify and call out the biggest infection control issues. By prioritizing, it becomes apparent which problems need to be addressed and a plan can be developed to do so.

  • Look at prevention strategies. What can be done to decrease risk to the staff and residents? How can the infection rate be decreased? What issues should the team stay on top of and what issues can be let go of (just a little)? What processes need to be implemented to sustain improvement? Is a more robust hand hygiene program necessary? Should the environmental cleaning process be revisited? Does the policy and procedure for post-op dressing changes need to be addressed?

Infection prevention programs can make or break a facility along with the staff that oversees it.

Following completion of the risk assessment, formulate the infection control plan and annual goals-SMART goals, or Specific, Measurable, Aligned, Realistic and Time bound. In the continuum of infection control, the outcomes of the measures taken to decrease infections are tracked through surveillance.


Investigate, prevent and control infections throughout the facility based on the risks identified through infection surveillance. Total house surveillance identifies every infection that occurs in the facility, and classifies those infections into categories of urinary tract, upper respiratory, lower respiratory, gastrointestinal, skin and soft tissue and surgical site infections.

Targeted surveillance is a more practical approach in long-term care, focusing on the infections that pose the greatest risk within a specific population. In many settings, the infections posing the greatest risk are device-related in residents with invasive devices such as indwelling urinary catheters, central venous catheters and mechanical ventilation.

In settings where invasive devices are not common, the most significant risks may be respiratory infections and poor compliance with influenza and pneumococcal vaccination.

Device-related infection rates are calculated using the formula below. The numerator represents the number of cases (in this case catheter-associated urinary tract infection [UTI]) and the denominator represents the population-at-risk. The quotient is multiplied by a constant to express a meaningful rate (Table A).

Table A. Device-related infection rate calculation

Population-related infection rates are also calculated using the number of cases as the numerator and the population-at-risk as the denominator (Table B).

While the equation appears simple and straightforward, infection surveillance can be challenging in long-term care. Calculating device-days for the denominator requires consistent and routine tracking of devices. This can be done manually by keeping a daily log of residents with the invasive device and counting the number of device-days at the end of the month or quarter. In some facilities, the staff is empowered to take ownership of this task. The value of staff involvement is immeasurable when striving to decrease the use of invasive devices.

In addition, infections are often difficult to identify in the elderly population for many reasons including poor fever response; limited independence with personal hygiene, which includes oral care and handwashing; and functional and cognitive changes making it difficult to evaluate symptoms. Standard surveillance definitions should be used to systematically identify infections based on clinical and lab criteria. The McGeer definitions, developed by Allison McGeer in 1991 for use in LTC facilities, are based mostly upon clinical criteria and less on cultures and other labs. This is partly because laboratory support has not always been readily available in long-term care. These definitions are due to be updated this year in collaboration with the National Healthcare Safety Network (NHSN). The updated definitions are likely to place a greater emphasis on lab results, as these services have played a greater role in long-term care over the past two decades.

Table B. Population-related infection rate calculation

Sherrie Dornberger, RN, CDONA, FACDONA, is President of the National Association Directors of Nursing Administration/LTC (NADONA). Jane Kirk, RN, MSN, CIC, is Clinical Manager at GOJO industries. For 10 years, Trina Zabarsky, RN, MSN, CIC, has been an Infection Preventionist for the Cleveland VA system. Long-Term Living 2011 September;60(9):42-45

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