Infection Management for Geriatrics in Long Term Care Facilities

84 Cobbs cussed with surrogates speaking on behalf of residents who make known their preferences for healthcare interventions. The unequal balance of power in the doctor-patient relationship is exagger- ated in the LTCF. Outside the confines of the LTCF, the doctor has an advantage in power by having knowledge of medicine and of the patient, whereas the patient has little knowledge of either the doctor or medicine. In the LTCF, the physician becomes even more powerful and controls many aspects of the resident’s life by writing orders. Choice of physicians is limited to a few staff doctors or others who are willing to be credentialed and to visit the LTCF. Access to the doctor is usu- ally determined by institutional routine, where the nurses serve as gatekeepers of physician access. On this uneven playing field, physicians must find ways to build trust with their patients so that difficult decisions can be made with the greatest possible au- tonomy and beneficience. Resident rights, such as the right to be given informa- tion about proposed or potential treatments and alternatives and the right to refuse treatment, serve as safeguards to counterbalance enhanced physician power. Con- flict between patient and doctor over treatment choices usually occur when they disagree about values and when trust is lacking (10). Agreement over the desir- ability of treatments depends on the ability of the physician and patient to negoti- ate to develop a shared understanding of the patient’s values and goals for care in the context of the medical treatment options. “. . . autonomy is not a zero-sum game but a complex network of relationship obligations, which can be negotiated in one way under certain circumstances and in another way when the situation changes” (11). V. DECISIONAL CAPACITY “Rarely is incapacity absolute; even people with impaired capacity usually pos- sess some ability to comprehend, to communicate, and to form and express a pref- erence” (12). Enhancing autonomous decision-making has received considerable atten- tion in recent years, particularly since the Patient Self Determination Act (PSDA) became effective in 1991. The PSDA is a federal statute that requires patients be informed of their right to participate in medical decision-making and to write ad- vance directives. Assessment of decisional capacity is complex. Decisional ca- pacity is decision specific and may vary over time. The resident with decisional capacity must demonstrate the ability to choose among various therapeutic goals, understand and communicate relevant information, and reasonably apply that in- formation to decision-making in keeping with those goals. Substantial numbers of residents of LTCFs may have been excluded from participating in discussions about care preferences because of an inability to determine decisional capacity

Ethical Issues 85 (13). Guidelines for determining decisional capacity are being developed and studied (12). When a resident is judged to lack decision-making capacity around a certain issue, the surrogate (durable power of attorney for healthcare decisions or next of kin) should be consulted to speak on behalf of the resident. A. Quality of Life Quality measures in LTCFs span several domains, including quality of life, qual- ity of care, and residents’ rights. Quality of life is an important goal of care in the nursing home (14). Some evidence shows that overall quality of life has improved for men and women older than 85 living in LTCFs (15). Nursing home leaders and patient care advocates report the three most important components of quality of life items as: dignity, self-determination and participation, and accommodation of resident needs (16). Achievement of these is found in the fabric of nursing home life, especially in the choice and control that residents have over daily issues. Res- idents attach great importance to choice and control over matters such as bedtime, rising time, food, roommates, care routines, use of money, use of the telephone, trips out of the nursing home, and initiating contact with the physician (17). Mea- surement of quality of life of cognitively impaired residents may be difficult. Of- ten even elderly persons with significant cognitive impairment can still answer questions about their quality of life (18). In addition, a surrogate often knows only a little about a resident’s satisfaction with care. Physicians and nurses appear to have limited insight into the health-related quality of life of nursing home resi- dents and probably should not be used as proxies when resident-based assess- ments can be obtained (19). Physicians may be able to affect perceived quality of life by making themselves more accessible to residents for questions and by ne- gotiating and communicating directly with residents about proposed interventions that require trips out of the nursing home (e.g., consultations, diagnostic studies). B. Advance Directives 1. Preferences for Treatment Advance directives are designed to preserve resident autonomy through future states of incapacity. Advance directives are written documents that reflect resident preferences for care, as articulated through developing goals of care and the gen- eral care plan. All residents (or their surrogates) should be provided with the op- portunity to articulate advance directives. Most LTCFs offer printed educational materials and processes for recording advance directives. Nondepressed, nonde- mented residents of LTCFs generally exhibit stable preferences for treatment when asked about cardiopulmonary resuscitation, intravenous antibiotics, me- chanical ventilation, and artificial nutrition. They distinguish clearly between

86 Cobbs time-limited and indefinite treatment plans. They generally favor receiving intra- venous antibiotics and limited mechanical ventilation, but reject most other treat- ments (20). In advanced chronic illness when death is expected, residents of LTCFs may have advance directives that articulate primary goals of care around the achievement of comfort and dignity. Under such circumstances, residents (or their surrogates) may direct healthcare professionals to implement treatment in- terventions to manage symptoms (e.g., pain control, relief of dyspnea), but not to prolong life. In such cases, advance directives might call for no cardiopulmonary resuscitation, no ventilator use, no feeding tube, no hospitalization (unless un- comfortable symptoms cannot be controlled in the nursing home), no intravenous fluids, no antibiotic treatment, and no laboratory studies. 2. Designating a Healthcare Proxy Residents should be encouraged to designate a healthcare proxy, that is, someone to speak for them in the event they lose capacity to make healthcare decisions. The physician should communicate with the healthcare proxy (surrogate) when the resident cannot participate in decision-making. In this way, the autonomy of the resident is best preserved, despite the existence of cognitive or functional deficits that preclude personal participation in decision-making. In many cases, the next of kin will serve as the surrogate, but the physician should be aware of the legal standing of the surrogate, to be sure that the authority to speak on behalf of the res- ident is indeed delegated to the person acting as surrogate. Other kinds of health- care proxy include durable power of attorney, guardian, and conservator. Differ- ences in healthcare proxy completion rates across different ethnic groups appear to be related to reversible barriers such as lack of knowledge and the perceived ir- relevance of advance directives (21). C. Decision to Hospitalize “Transfer rates vary widely among nursing facilities and over time . . . Nursing fa- cilities differ in case mix, in the number of residents with advance directives, and in clinical care resources” (22). Decisions about whether to hospitalize residents with infectious problems arise frequently in LTCFs. Pneumonia is the leading cause of hospitalization among nursing home residents, with a mortality in some studies of 40% to 50% (23). In the past, acute care facilities and LTCFs have offered distinctly different types of health services; treatment capabilities currently overlap. Differences be- tween acute and long-term care settings still potentially include numbers and types of practitioners, sources of financial reimbursement, and philosophy of approach to the management of chronic diseases (24). The desirability and appropriateness of transfers of LTCF residents to hos- pitals provokes debate because of concern about cost, but also because of adverse

Ethical Issues 87 effects of hospitalization (25). Physically frail long-term residents are the most likely to be hospitalized, but they may also be the least likely to benefit from hos- pitalization (26). Iatrogenic complications and emotional trauma for residents and families have been cited as adverse effects of hospitalization. Advancing age, lower admission Mini-Mental State Examination scores, and lower preadmission instrumental activities of daily living functional characteristics are independent risk factors for functional decline during hospitalization of older persons (27). Treatment of pneumonia in the LTCF may produce better outcomes for some pa- tients than if they were hospitalized (28). Many patient, institutional, and physi- cian factors affect this decision. Goals of care and the institution’s capacity to pro- vide appropriate diagnostic and treatment interventions in a timely fashion are of particular importance. The physician’s obligation is to determine the course that best serves the needs and goals of the resident. D. Right to Refuse Care Residents who have the capacity to make decisions about healthcare matters have the right to refuse care. A major reason patients refuse a recommended care inter- vention is that they misconstrue or misunderstand the recommendation. Because much communication in LTCFs is accomplished through the interdisciplinary care team, the physician’s response to a resident refusing care ought to include a personal visit under comfortable, private, unhurried circumstances to discuss the proposed treatment with the resident (or surrogate). If outright disagreement be- tween resident and physician continues, this is likely because of a difference in values. The refusal of amputation of a gangrenous extremity is sometimes en- countered in LTCFs. Some regard the prospect of amputation as a fate worse than death (29). It is often helpful to involve other members of the IDT to better un- derstand the reasons for the refusal and to try to create alternative plans for care that would be acceptable to the resident and yield the best available outcomes from the physician’s perspective. E. Advanced Dementia Dementia is an important condition affecting more than half the residents of LTCFs. Although residents with dementia may live many years, the disease is not curable, is inexorably progressive, and eventually ends in death. Decisions about treatment in advanced dementia are best carried out through development of the goals of care, as described above. Surrogates often adjust the goals of care as the disease and the resident’s level of disability progress, when the burdens of treat- ment loom larger than the benefits. Surrogates and families often choose to shift the emphasis of care from a focus on reactive treatments for medical problems, such as pneumonia or urinary tract infection, to proactive interventions designed

88 Cobbs to enhance pleasure and quality of life, as in freedom from restraints. Guidelines to support decision-making about whether to treat or not treat pneumonia in de- mented psychogeriatric nursing home patients have proved useful in some settings (30). When the goals of care are totally focused on achieving comfort and death is expected, as in a patient with very advanced dementia, it is not uncommon for families and surrogates to forego treating with antibiotics. F. Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Since the treatment advances of the mid 1990s, the outlook for those living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) has brightened considerably. Long-term care options will be increasingly needed for patients who do not fully respond to antiretroviral therapy or who have significant neuropsychiatric disease (31). The HIV/AIDS residents have a variety of reasons for needing long-term care, including the need for 24-hour nursing/medical supervision, completion of medical treatment, and end-of-life care. Issues pertaining to the need for advance care planning and palliative care are particularly important for HIV/AIDS residents. VI. HEALTH PROMOTION Health promotion remains an important dimension of high-quality health care in LTCFs. Immunizations are a particular focus of effective health promotion and are safe for even frail residents. Influenza is an important cause of epidemic and endemic respiratory illness in LTCFs and results in considerable morbidity and mortality. The annual vaccination of residents and staff remains the most effective way to prevent influenza and its complications. However, vaccination rates have fallen short of public health targets. Facilities should develop resident and staff vaccination programs to improve the rate of vaccination (32). Pneumococcal vac- cine and annual tuberculin skin testing are also recommended. Other health pro- motion activities, such as maintaining the highest level of mobility and function possible, are important in preventing deep venous thromboses, pressure ulcers, and other conditions associated with immobility. VII. ROLE OF THE IDT Effective IDTs are essential to the provision of high-quality care in LTCFs and can alleviate many of the ethical dilemmas that characterize life in these institu-

Ethical Issues 89 tions. The dominant providers in these facilities are nursing aides who render the majority of the direct care to residents. The ability of the nursing aide to recognize a change in the resident’s status and bring it to the attention of the medical practi- tioner permits the earliest possible identification of an infectious problem. This system of surveillance compensates for the atypical presentation that commonly characterizes illnesses of the frail elderly resident. Nurses view advocacy as a re- sponsibility of their practice, where advocacy is rooted in the concept of individ- ual rights (33). Social workers also practice an advocacy role, supporting three el- ements of autonomy: free action (supporting residents’ choices), decision-making (helping residents deliberate effectively), and continuity (maintaining a sense of self) (34). Geriatric nurse practitioners help to achieve optimal coordination of care and reduce emergency department and acute care utilization costs as well as overall costs for some managed care programs for LTCF residents (35). The key to effective IDT functioning is good communication that facilitates the flow of in- formation to the team member who is best able to recognize its significance and respond appropriately. VIII. INTERVENTIONS: BURDENS AND BENEFITS Diagnostic and treatment interventions bring benefits and burdens for the resident. Resident (or surrogate) decisions to accept or decline treatment may in part be de- termined by the perceived burdens of treatment interventions. Less burdensome options may exist. In-and-out bladder catheterization, for example, can be a fright- ening and uncomfortable procedure for a frail, elderly women. Investigators have demonstrated that urine specimens can be collected externally from incontinent female LTCF residents (36). Intravenous antibiotic therapy of a resident with de- mentia who pulls out the intravenous line on a daily basis brings the burden of re- peated needlesticks and perhaps physical restraints. For an extremely debilitated resident, even transportation for a diagnostic test may be exceedingly burdensome because of discomfort from prolonged periods of waiting and riding in a bumpy wheelchair van, fear of uncertainty and a strange environment, and risk of falls from caregivers unfamiliar with the resident’s level of functional capacity. Practi- tioners often can devise alternative plans that minimize treatment burdens, some- times with help from the IDT and outside consultants to assure resident comfort, control, and dignity. Consent should be sought from the resident or surrogate before embarking on a burdensome course of diagnostic testing or treatment intervention. Trials of treatment interventions may be helpful when there is ambivalence about declining or accepting an intervention. A time-limited trial (e.g., of tube feeding or hemodialysis) with the option to continue or discontinue treatment af- ter seeing how well it is tolerated may be helpful.

90 Cobbs IX. END-OF-LIFE CARE Long-term care facilities will play an increasingly important role in the care of people nearing the end of life. In 1993, 20% of U.S. deaths occurred in nursing homes. By 2040 this proportion is expected to rise to 40% (37). Improving care near the end of life for LTCF residents goes beyond advance care planning and advance directives. Effective symptom management, maximization of functional capacity, and assistance with issues pertaining to life closure are additional im- portant services that must be offered consistently as part of a system that achieves good care for those nearing the end of life. Over the past few years, the healthcare profession has recognized the need to improve the quality of care for people near the end of life, but consensus about how to accomplish this has not yet been achieved. Those living with serious chronic illness near the end of life are likely to follow one of three trajectories: (1) a relatively brief period of severe functional decline at the end of life (typical of cancer); (2) long-term disability with periodic exacerbations and unpredictable timing of death (as in congestive heart failure and chronic obstructive pulmonary disease); or (3) slow dwindling course to death with significant self-care deficits (usually from extreme frailty or dementia). These trajectories shed light on possi- ble care systems that would serve residents’ needs better (38). A number of studies have identified effective communication and pain man- agement as shortcomings in the care of dying persons. Bereaved family members are generally satisfied with life-sustaining treatment decisions but voice concerns about failures in communication and pain control. Nursing home care has received the smallest proportion of positive comments, including mention of poorly trained or inattentive staff and remoteness of physicians. Families recommend that care could be improved through better communication, greater access to physicians’ time, and better pain management (39). LTCF residents near the end of life are focused on the quality of living rather than dying. They have concerns with day-to-day living, difficulty chewing and swallowing, better pain relief and sense of control, strengthening relationships with loved ones, importance of religious activities, giving care to others, and ap- preciation of respectful and prompt care (40,41). X. CONTACT ISOLATION Although prevalence of antibiotic-resistant bacteria in LTCFs has been de- scribed, managing residents colonized with antibiotic-resistant organisms has come to represent a significant challenge for practitioners in these settings (42). Contact isolation of a resident colonized with a resistant organism represents an affront to that resident’s freedom created by the obligation to protect the rights

Ethical Issues 91 of other residents to be free from harm, particularly those in subacute settings. Adverse effects of contact isolation include less frequent care and negative psy- chological consequences (43). There are likely to be significant differences be- tween different types of LTCFs (e.g., the Veterans Affairs nursing home care unit population vs community nursing home population) (44). More needs to be learned about the risk to residents and how to develop antibiotic resistance pre- cautions that are effective, inexpensive, and achievable in LTCFs. The IDT may address the psychological problems that the isolated resident experiences and develop strategies to avoid unnecessary complications of isolation procedures. For example, the IDT might permit a resident to wash his face and hands, don a clean gown, and walk in the halls to physical therapy at the end of the day (see chapters in Part III and Chapter 8). XI. COST CONCERNS The varied arrangements for financing care in the LTCF create a variety of ethi- cal dilemmas for facilities and practitioners. Every treatment option has a cost that must be factored into the process of clinical decision-making. Financial incentives to accept residents with complex medical needs into the facility exist with some payors but not with others. Some payors encourage transfer of the acutely ill res- ident to the hospital and others reward the LTCF and the practitioner for treating the resident in the LTCF. The high cost of antibiotics such as vancomycin may create significant dilemmas. In some cases, for cost reasons, residents may not be able to return to the LTCFs they consider home. Significant variation exists in pre- scribing and the cost of antimicrobials among LTCFs (45), and formularies and guidelines are being developed to standardize prescribing practices. XII. INFECTION CONTROL PRACTICES BY STAFF The LTCF staff plays an important role in infection control through the use of pre- cautions and routines (see Chapters 8 and 9). From an ethics standpoint, these are measures that carry little risk or burden to the staff and are effective in maintain- ing infection control. Hand washing is perhaps the most obvious low risk strategy, yet marked shortcomings in the use of hand washing and gloves continue to exist in LTCFs (46). Hand-washing practices vary considerably across hospital wards and type of worker, and lack of good hand washing appears to be associated with understaffing (47). A common ethical dilemma is the question of whether a sick employee should be working. Prohibiting a staff member with a contagious illness from working with residents follows from the ethical concept of utility that strives to

92 Cobbs maximize good outcomes while minimizing harm. Institutional staffing shortfalls or the staff member’s reluctance to take a sick day may compete with this value. Another ethical quandary is presented when staff members fail to get in- fluenza vaccines. The medical director should work with infection control profes- sional and other members of the IDT to create an institutional ethic of good in- fection control practices, supported by strong educational programs for staff and effective employee health services. XIII. ROLE OF THE MEDICAL DIRECTOR The medical director bears responsibility for the overall quality of care provided in the LTCF. Along with the director of nursing and the facility administrator, the medical director should develop a basic ethics policy framework (48). Effective implementation of ethics policies requires a shared vision by the leadership, ade- quate support for the process, and explicit guidelines for the staff and practition- ers, residents, and families. A mechanism to resolve disputes should be developed. Ethics committees have fulfilled this role in some facilities. Measuring outcomes that reflect quality of care in LTCFs is an important di- mension of quality management for which the medical director has oversight. The Minimum Data Set (MDS) has provided some quality indicators for LTCFs (such as pressure ulcers, use of psychotropic medications, falls) but other measures need to be developed. Needs for pain relief and spiritual support are not routinely ad- dressed by the MDS and Resident Assessment Protocol (RAP) triggers. Indicators are likely to vary for different subsets of LTCF residents. Key in- dicators for the care of terminally ill residents include communication of advance directives, attention to pain management, and relief of dyspnea (49). For residents who desire antibiotic treatment for infectious diseases, early empiric antibiotic therapy has an important impact on the outcomes of pneumonia (50); thus, percent of residents who received antibiotics within 4 hours of diagnosis of infection might be a worthwhile quality indicator. XIV. RESEARCH ISSUES IN INFECTION CONTROL Research is an important avenue in improving treatment and preventing infectious disease in LTCF residents. There are multiple facets of ethical obligation in the LTCF research endeavor. Guidelines for ethical investigations have been put forth (51). The Ethics Committee of the American Geriatrics Society has outlined guidelines for appropriateness of the informed consent process for patients with dementia who are research subjects (52). The interest of the individual resident may be at times in opposition to the interests of the population within the facility.

Ethical Issues 93 A mandate to do no harm and protect confidentiality exists for both the individual and the population. However, the individual resident seeks privacy and autonomy, whereas the concern of the population lies in investigating, reporting, and achiev- ing justice. Infection control activities ought to investigate clusters of adverse out- comes, identify and implement cost-effective interventions, safeguard the health of residents and staff, measure the efficacy of interventions, and avoid conflicts of interest around recommendations of products and equipment. Residents who be- come subjects for research (or their surrogates) must provide informed consent, and they must be assured that their welfare, privacy, and confidentiality will be protected. Staff members should be protected from harm (taking precedence over staff freedom)(5). Although basic standards of research ethics are not usually re- ported in nursing home research, the instructions of a journal for the author or other features of peer review can affect the quality of reporting research ethics (53). Well-written policies on the protection of cognitively impaired research sub- jects is an important way that research institutions can demonstrate that serious at- tention is paid to the rights and welfare of cognitively impaired residents (54). XV. FUTURE Long-term care facilities are likely to continue to be places where functionally de- pendent persons receive medical and personal care, either episodically or as a final place of residence toward the end of life. The ethical issues interwoven into Table 2 Promises to Those with Advanced Stages of Serious Illness 1. GOOD MEDICAL TREATMENT—You will have the best of medical treatment, aiming to prevent exacerbation, improve function and survival, and ensure comfort. 2. NEVER OVERWHELMED BY SYMPTOMS—You will never have to endure overwhelming pain, shortness of breath, or other symptoms. 3. CONTINUITY, COORDINATION, AND COMPREHENSIVENESS—Your care will be continuous, comprehensive, and coordinated. 4. WELL PREPARED, NO SURPRISES—You and your family will be prepared for everything that is likely to happen in the course of your illness. 5. CUSTOMIZED CARE, REFLECTING YOUR PREFERENCES—Your wishes will be sought and respected, and followed whenever possible. 6. USE OF PATIENT AND FAMILY RESOURCES (financial, emotional, and practical)—We will help you and your family consider your personal and financial resources, and we will respect your choices about the use of those resources. 7. MAKE THE BEST OF EVERY DAY—We will do all we can to see that you and your family have the opportunity to make the best of every day. Source: Adapted from Ref. 55.

94 Cobbs this environment are powerful determinants of the outcomes that LTCF residents experience. An articulation of a vision for the future guides practitioners and others to achieve the best possible quality of life and care for LTCF residents (Table 2) (55). REFERENCES 1. Garibaldi RA. Residential care and the elderly: The burden of infection. J Hosp Infex 1999; 43 Suppl:S9–S18. 2. Yoshikawa TT, Norman DC. Approach to fever and infection in the nursing home. J Am Geriatr Soc 1996; 44:74–82. 3. Dubler NN. Reflections on some ethical issues in long-term care. In: Binstock RH, Cluff LE, Von Mering O (eds). The Future of Long-Term Care: Social and Policy Is- sues. Baltimore, Johns Hopkins Press, 1996:238–251. 4. Olson MD. “The heart still beats, but the brain doesn’t answer.” Perception and ex- perience of old-age dementia in the Milwaukee Hmong community. Theoretical Med Bioethics 1999; 20(1):85–95. 5. Herwaldt LA. Ethical aspects of infection control. Infect Control Hosp Epidemiol 1996; 17:108–113. 6. Tsevat J, Cook F, Green ML, Matchar DB, Dawson NV, Broste SK, Wu AW, Phillips RS, Oye RK, Goldman L, for the SUPPORT Investigators. Health values of the seri- ously ill. Ann Intern Med 1995; 122:514–520. 7. Vaughn G, Kiyasu E, McCormick WC. Advance directive preferences among sub- populations of Asian nursing home residents in the Pacific Northwest. J Am Geriatr Soc 2000; 48:554–557. 8. Gillick M, Berkman S, Cullen L. A patient-centered approach to advance medical planning in the nursing home. J Am Geriatr Soc 1999; 47:227–230. 9. Quill TE, Brody H. Physician recommendations and patient autonomy: Finding a bal- ance between physician power and patient choice. Ann Intern Med 1996; 125: 763–769. 10. Lantos JD. Futility assessments and the doctor-patient relationship. J Am Geriatr Soc 1994; 42:868–870. 11. Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Eng J Med 2000; 343:293–296. 12. Mezey M, Teresi J, Ramsey G, Mitty E, Bobrowitz T. Decision-making capacity to execute a health care proxy: Development and testing of guidelines. J Am Geriatr Soc 2000; 48:179–187. 13. Bradley E, Walker L, Blechner B, Wetle T. Assessing capacity to participate in dis- cussions of advance directives in nursing homes: Findings from a study of the Patient Self Determination Act. J Am Geriatr Soc 1997; 45:79–83. 14. Ouslander JG, Osterweil D. Physician evaluation and management of nursing home residents. Ann Intern Med 1994; 121:584–592. 15. Liao Y, McGee DL, Cao G, Cooper RS. Quality of the last year of life of older adults: 1986 vs 1993. JAMA 2000; 283:512–518. 16. Harrington C, Mullan J, Woodruff LC, Burger SG, Carrillo H, Bedney B. Stakehold-

Ethical Issues 95 ers’ opinions regarding important measures of nursing home quality for consumers. Am J Med Qual 1999; 14:124–132. 17. Kane RA, Caplan AL, Urv-Wong EK, Freeman IC, Aroskar MA, Finch M. Everyday matters in the lives of nursing home residents: Wish for and perception of choice and control. J Am Geriatr Soc 1997; 45:1086–1093. 18. Mozley CG, Huxley P, Sutcliffe C, Bagley H, Burns A, Challis D, Cordingley L. “Not knowing where I am doesn’t mean I don’t know what I like”: Cognitive impairment and quality of life responses in elderly people. Int J Geriatr Psychiatry 1999; 14(9):776–783. 19. Berlowitz DR, Wei D, Kazis L, Lewis S. Health-related quality of life of nursing home residents: Differences in patient and provider perceptions. J Am Geriatr Soc 1995; 43:799–802. 20. Berger JT, Majerovitz D. Stability of preferences for treatment among nursing home residents. Gerontologist 1998; 38:217–223. 21. Morrison RS, Zayas LH, Mulvihill M, Baskin SA, Meier DE. Barriers to completion of health care proxies: An examination of ethnic differences. Arch Intern Med 1998; 158:2493–2497. 22. Saliba D, Kington R, Buchanan J, Bell R, Wang M, Lee M, Herbst M, Lee D, Sur D, Rubenstein L. Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc 2000; 48:154–163. 23. Beck-Sague C, Banerjee S, Jarvis WR. Infectious diseases and mortality among US nursing home residents. Am J Public Health 1993; 83:1739–1742. 24. Phillips-Harris C, Fanale JE. The acute and long-term care interface: Integrating the continuum. Clin Geriatr Med 1995; 11:481–501. 25. Creditor MD. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118:2199–2223. 26. Fried TR, Mor V. Frailty and hospitalization of long-term stay nursing home resi- dents. J Am Geriatr Soc 1997; 45:265–269. 27. Sager MA, Rudberg MA, Jalaluddin M, Franke T, Inouye SK, Landefeld S, Siebens H, Winograd CH. Hospital admission risk profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc 1996; 44:251–257. 28. Fried TR, Gillick MR, Lipsitz LA. Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. J Am Geriatr Soc 1997; 45:302–306. 29. Donohue SJ. Lower limb amputation: Some ethical considerations. Brit J Nurs 1997; 6:1311–1314. 30. Van der Steen JT, Muller MT, Ooms ME, van der Wal G, Ribbe MW. Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: Development of a guideline. J Med Ethics 2000; 26:114–120. 31. Selwyn PA, Goulet JL, Molde S, Constantino J, Fennie KP, Wetherill P, Gaughan DM, Brett-Smith H, Kennedy C. HIV as a chronic disease: Implications for long-term care at an AIDS-dedicated skilled nursing facility. J Urban Health 2000; 77:187–203. 32. McArthur MA, Simor AE, Campbell B, McGeer A. Influenza vaccination in long- term care facilities: Structuring programs for success. Infect Control Hosp Epidemiol 1999; 20:499–503.

96 Cobbs 33. Fisher PS. Patient’s Bill of Rights Act 1998. ORL—Head and Neck Nursing 1999; 17:13–15. 34. Reinardy JR. Autonomy, choice, and decision-making: How nursing home social workers view their role. Social Work Health Care 1999; 29:59–77. 35. Burl JB, Bonner A, Rao M, Khan AM. Geriatric nurse practitioners in long-term care: Demonstration of effectiveness in managed care. J Am Geriatr Soc 1998; 46: 506–510. 36. Ouslander JG, Schapira M, Schnelle JF. Urine specimen collection from incontinent female nursing home residents. J Am Geriatr Soc 1995; 43:279–281. 37. Brock DB, Foley DJ. Demography and epidemiology of dying in the U.S. with em- phasis on deaths of older persons. Hosp J 1998; 13:49–60. 38. Lynn J. Serving patients who may die soon and their families. JAMA 2001; 285:925–932. 39. Hanson LC, Danis M, Garrett J. What is wrong with end-of-life care? Opinions of be- reaved family members. J Am Geriatr Soc 1997; 45:1339–1344. 40. Engle VF, Fox-Hill E, Graney MJ. The experience of living-dying in a nursing home: Self-reports of black and white older adults. J Am Geriatr Soc 1998; 46:1091–1096. 41. Singer PA, Martin DK, Kelner M. Quality end-of-life care: Patients’ perspectives. JAMA 1999; 281:163–168. 42. Bradley SF. Issues in the management of resistant bacteria in long-term care facili- ties. Infect Control Hosp Epidemiol 1999; 20:362–366. 43. Kirkland KB, Weinstein JM. Adverse effects of contact isolation. Lancet 1999; 354:1177–1178. 44. Mulhausen PL, Harrell LJ, Weinberger M, Kochersberger GG, Feussner JR. Con- trasting methicillin-resistant Staphylococcus aureus colonization in Veterans Affairs and community nursing homes. Am J Med 1996; 100:24–31. 45. Mylotte JM. Antimicrobial prescribing in long-term care facilities: Prospective eval- uation of potential antimicrobial use and cost indicators. Am J Infect Control 1999; 27:10–19. 46. Thompson BL, Dwyer DM, Ussery XT, Denman S, Vacek P, Schwartz B. Hand washing and glove use in a long-term-care facility. Infect Control Hosp Epidemiol 1997; 18:97–102. 47. Pittet D, Mourouga P, Perneger TV, and the Members of the Infection Control Pro- gram. Compliance with hand washing in a teaching hospital. Ann Intern Med 1999; 130:126–130. 48. Levenson SA. Medical Direction in Long-Term Care: A Guidebook for the Future. Durham, NC, Carolina Academic Press, 1993. 49. Keay TJ, Fredman L, Taler GA, Datta S, Levenson SA. Indicators of quality medical care for the terminally Ill in nursing homes. J Am Geriatr Soc 1994; 42:853–860. 50. Feldman C. Pneumonia in the elderly. Clin Chest Med 1999; 20:563–573. 51. Sachs GA, Rhymes J, Cassel CK. Biomedical and behavioral research in nursing homes: Guidelines for ethical investigations. J Am Geriatr Soc 1993; 41:771–777. 52. American Geriatrics Society Ethics Committee. Informed consent for research on hu- man subjects with dementia. J Am Geriatr Soc 1998; 46:1308–1310. 53. Karlawish JH, Hougham GW, Stocking CB, Sachs GA. What is the quality of the re-

Ethical Issues 97 porting of research ethics in publications of nursing home research? J Am Geriatr Soc 1999; 47:76–81. 54. Cahill M, Wichman A. Research involving persons with cognitive impairments: Re- sults of a survey of Alzheimer disease research centers in the United States. Alzheimer Dis Assoc Disorders 2000; 14:20–27. 55. Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians. New York, Oxford University Press, 2000.



8 Nursing Management of Infections Donna L. Barton Lake Eustis Care Center, Eustis, Florida Janet D. Register Leesburg Regional Medical Center, Leesburg, Florida I. INTRODUCTION When caring for residents in a long term-care facility (LTCF), infections are fre- quently encountered. Each facility must have an infection control program as mandated by Federal regulation (1). This program is designed to investigate, con- trol, and prevent infections in the facility; decide what procedures, such as isola- tion, should be applied to an individual resident; and maintain a record of incidents and corrective actions related to infections. In the August 1991 Journal of Infection Control, the Association for Practi- tioners in Infection Control (APIC; now called Association for Professionals in In- fection Control and Epidemiology), published “APIC guideline for infection preven- tion and control in the long-term care facility” (2). This article assists in establishing an infection control program for LTCFs. It provides information on how to establish an effective surveillance program. Total surveillance is recommended for all residents for whom antibiotic therapy is prescribed while residing in LTCFs. This includes re- viewing the medical history of residents admitted to the facility with antibiotic orders (community-acquired infections), as well as those who developed infections and were given antibiotic therapy while residing in an LTCF (nosocomial infections). II. SURVEILLANCE The purpose of surveillance is to identify trends that may be occurring so that a potential outbreak can be avoided and to determine educational needs for the en- 99

100 Barton and Register tire staff caring for the residents. An important part of surveillance is to establish criteria for identifying infections of various body systems. In February 1991, the American Journal of Infection Control published an article entitled “Definition of infections for surveillance in long-term care facilities,” which can serve as a ref- erence in establishing these criteria (3). Contributors to this informative article in- cluded representatives from APIC, Centers for Disease Control and Prevention (CDC), and many teaching hospitals throughout the United States and Canada. Using this as a guide and working with the facility medical director, criteria can be formulated for those symptoms that best signal an infection (see the appendixes of this book for summary of these criteria). A reliable method to help the nurse identify the presence of infection in res- idents is the basic “nursing process” of assessment, diagnosis, planning, imple- mentation, and evaluation (4) (Table 1). All items of the nursing process should be reviewed by the nurse before the physician is given the assessment findings of a resident suspected of having an infection. The purpose of the nursing process is to compile an accurate, concise, com- prehensive resident assessment to present to the physician. Important information includes the following: • Current physician orders • The most recent physician progress notes • The resident’s current medications • Vital signs, if applicable • Any abnormal laboratory or radiology finding available • A brief history of the resident’s current problem Table 1 Basic Nursing Process Assessment Use criteria adopted for presence of infection in specific body system. Collect data through interview with resident for subjective and Diagnosis Planning objective complaints, review of history, medical record, and physical examination. Implementation Compile the assessment findings and laboratory results in a systematic Evaluation method for presentation to physician for diagnosis. Obtain physician orders, list needed comfort measures, identify appropriate room placement for containment, identify necessary isolation precautions as indicated by symptoms and physician diagnosis. (Care Planning Process for significant change.) Carry out individualized plan of care as established. Follow-up on outcomes of implementation of plan of care. If symptoms continue, return to assessment, presentation of information to physician for diagnosis, alteration of Care Plan, implementation of new Care Plan, and evaluation of outcomes.

Nursing Management of Infections 101 The nurse should keep the resident’s chart available for writing any new physician orders or for access to any additional information. III. IDENTIFICATION OF INFECTIONS A. Clinical Manifestations Once criteria for identifying nosocomial infections have been formulated by the facility’s infection control committee, it is important to remember that not all LTCF residents with infection will present with these symptoms. Atypical clini- cal manifestations are not unusual in the elderly. Often a temperature elevation is thought to be the first sign of an infection. In the elderly, however, fever may be absent or the body temperature may be below normal (see Chapter 6). And an early sign of pneumonia may only be tachypnea (5–7). There is a need to profile each individual resident as to past symptoms and signs of a specific infectious process. There are instances in which the only evidence of an infectious process is a change in normal behavior patterns, a change in mentation, a decrease in the resident’s normal activity level, or poor fluid and food intake. Some residents may have symptoms compatible with an infection, but due to dementia, aphasia, or nonresponsiveness, they are unable to communicate their presence. Ev- ery LTCF has at least one resident who has been labeled a “chronic complainer.” Re- gardless of past experience with this type of resident, each new complaint necessi- tates a thorough nursing assessment and physician notification, if indicated. B. Diagnostic Specimens and Microbiology The physician may ask for a specimen to be obtained for culture and sensitivity. Nurses need to be trained in the proper technique of obtaining specimens as indi- cated by the receiving laboratory. Nurses will also review the findings in the cul- ture and sensitivity reports for communication to the physician. If no organism was found and the physician has prescribed an antibiotic, it is imperative for the nurse to notify the physician of the culture results. If an organism is found, the sensitiv- ity report will identify whether the antibiotic ordered for treatment is effective or if the organism is resistant to the drug. If the infecting organism is resistant, the nurse must relay this information to the physician, along with a list of antibiotics to which the organism is sensitive. Antibiotic use must be closely monitored for its appropriateness to assist in decreasing the possibility of drug-resistant pathogens. C. Communication The identification of infections is a team effort. All staff must be involved: nurses, nursing assistants, therapists, environmental, dietary, and any other facility staff.

102 Barton and Register Family members, visitors, and volunteers who come in contact with the resident routinely can also identify a change in that resident and provide information for nurses. It is important to establish lines of communication with all team members, families, visitors, and volunteers. Most frequently, these individuals will commu- nicate their concerns to the nurse in charge of the resident’s care. The nurse must listen and be aware that a potential problem may exist that requires further resi- dent assessment. It is particularly vital to investigate the concerns of nursing as- sistants regarding residents for whom they are caring. Nursing assistants are the direct caregivers who spend the most time with the residents and will most often be first to identify changes in the resident’s behavior. However, because their medical education is limited, they do not always have the terminology to describe their findings, and nursing follow-up of their observations is often lacking. IV. PREVENTING INFECTIONS Knowing how infections spread is the first step in preventing their spread to staff members or other residents. The CDC recently published its Guidelines for Isola- tion Precautions in Hospitals (8). The categories for isolation precautions are stan- dard, droplet, airborne, and contact. A. Standard Precautions Standard precautions combines the features of universal precautions and body substance isolation. It applies these precautions to all persons receiving care in any type of medical establishment, regardless of diagnosis or presumed infection status. Standard precautions apply to blood and all body fluids; secretion and ex- cretions (except sweat), regardless of whether these fluids contain visible blood; nonintact skin; and mucous membranes. 1. Hand Washing The practice of standard precautions first addresses the importance of hand wash- ing. A 15-second hand washing will be performed (9). • After touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, contaminated items • Upon reporting to work at the start of the shift • Before and after each resident contact (it may be necessary to wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites) • After using the restroom

Nursing Management of Infections 103 • Before handling food • Before and after eating or smoking • Before and after handling patient care items • Before and after glove usage • Before leaving work area to go home • After blowing or wiping one’s nose Hand washing is to be performed at these times regardless of whether gloves are worn. With the increased encouragement of activities in LTCFs, residents are frequently found out of their room and in communal areas participating in the ac- tivities offered. With this increased mobility, residents themselves may be a source of infection to other residents. Just as hand washing is the key factor in pre- venting the spread of infection from the hands of the healthcare worker, so is fre- quent hand washing by the residents a deterrent in spreading infection to other res- idents (10). 2. Personal Protective Equipment (PPE) a. Gloves: These should be worn (clean, intact, nonsterile gloves are ade- quate) whenever the employee comes in contact with: • Moist body substances (e.g., blood, body fluids, secretions, and ex- cretions) • Mucous membranes (mouth, nose, eyes, genitals, and rectum) (Put on clean gloves just before touching mucous membranes and instill- ing eye drops.) (11) • Nonintact skin (Put on clean gloves just before touching nonintact skin.) • Any resident care items that may be contaminated with moist body substances (e.g., bedpans, urinals, linens) Remove gloves promptly after use and wash hands before touching noncontaminated items, environmental surfaces, and before going to another resident. This helps to prevent transferring microor- ganisms to other residents or the environment. Gloves should be re- moved and hands washed before leaving a resident’s room. b. Gown: Wear a clean, nonsterile gown to protect skin and to prevent contamination of clothing during resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or ex- cretions. Remove a soiled gown promptly and wash hands to avoid transfer of microorganisms to other residents or the environment. c. Goggles, face shields, and masks: Wear these items to protect mucous membranes of the eyes, nose, and mouth during resident care activities that are likely to generate splashes or sprays of blood, body fluids, se-

104 Barton and Register cretions, and excretions (e.g., emptying Foley bags, during resident suc- tioning, emptying suction canisters). d. Masks: These will be worn by staff members when a resident has an un- diagnosed cough. This protects the healthcare worker who may be sus- ceptible to an undiagnosed airborne disease carried by the resident. e. Resident care equipment: Handle all soiled resident-care equipment in a manner that prevents exposure to skin, mucous membranes, clothing, other residents, and the environment. • Reusable equipment must be cleaned and reprocessed appropriately before use by another resident, (e.g., intravenous poles, walkers, wheelchairs). • Ensure that single-use items are discarded properly. f. Linen: Handle, transport, and process used linen in a manner that pre- vents skin and mucous membrane exposures and contamination of clothing. Proper handling of linen will avoid transfer of microorganisms to other residents and the environment. 3. Occupational Health and Bloodborne Pathogens • Use safety devices, needleless systems, and procedures that help to min- imize needlesticks and sharps injuries (e.g., never recap, bend, or break needles). • Place used disposable syringes, needles, scalpel blades, razor blades, and other sharp items in appropriate puncture-resistant containers. These containers should be located as close as practical to the area in which the items were used. The containers should be changed when two-thirds to three-quarters full. • Use care in handling sharp instruments after use, including razor blades. • Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation. B. Airborne Precautions In addition to standard precautions, use airborne precautions for residents known or suspected of being infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue [5 microns or smaller in size] of evaporated droplets containing microorganisms that remain suspended in the air and can be dispersed widely by air currents within a room or over long distances). Airborne precautions are practiced to protect staff members, as well as any individual entering the precaution room. These precautions should be used for all residents diagnosed with or suspected of having active tuberculosis (TB), measles (rubeola), chickenpox (varicella), or herpes zoster.

Nursing Management of Infections 105 1. Resident Placement Residents should be placed in an isolation room. The room should: • have monitored negative air pressure in relation to the surrounding areas • have 6 to 12 air changes per hour • have appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the fa- cility • have the door closed at all times If there is no negative air pressure room in the facility, it will be necessary to transfer the resident to a facility that has appropriate accomodations. After the resident has been taking antituberculosis medications for at least 10 days, there is a marked improvement in symptoms, and the sputum smears are negative, the pa- tient is no longer considered communicable and may return to the LTCF. (Note: criteria for proven cases of TB to be allowed to return to home or LTCF may vary from state to state). To maintain confidentiality, post a sign outside the room ad- vising anyone preparing to enter the room to report to the nurses’ station. 2. Respiratory Protection • A particulate respirator mask, having the capacity to filter to 5 microns or less, should be worn by all employees and visitors entering the room of a resident with known or suspected TB or other airborne infections. • Employees who have not had measles or chickenpox, or been immu- nized for these infections, should not enter the room of residents with these infections, if other immune caregivers are available. • Persons immune to measles or chickenpox need not wear respiratory protection when caring for a resident with these infections. 3. Resident Transport Limit the transport of the resident from the room to essential purposes only. • Have diagnostic tests and procedures done in resident’s room rather than transporting the resident to other departments, when possible. • When resident must be transported out of the room to other departments, the resident is to wear a mask and the receiving department is to be alerted to the resident being on airborne precautions. 4. Education • Educate the resident and alleviate resident concerns about airborne pre- cautions.

106 Barton and Register • Inform resident to cover mouth and use tissues when coughing or sneez- ing, and teach the resident proper disposal of used tissues. • Educate visitors on the proper use of masks. • Keep employee and visitor traffic to a minimum. The termination of airborne precautions in a diagnosed or suspected TB case is permitted if: • TB has been excluded by smear and culture • The criteria for noncommunicability of an active TB case are met (see earlier discussion) • Resident is discharged home. C. Droplet Precautions In addition to standard precautions, use droplet precautions for a resident known to be or suspected of being infected with microorganisms transmitted by droplets (large particle droplets [larger than 5 microns in size] that can be generated by the resident during coughing, sneezing, talking, or during the performance of proce- dures). Droplet precautions are used to protect the staff, other residents, and fami- lies from infections transmitted by the droplet route. Droplet precautions should be instituted for all diagnosed or suspected cases of infections transmitted by droplets, for example, pertussis, diphtheria, Haemophilus influenzae, among others. 1. Resident Placement • All residents requiring droplet precautions will be admitted to a private room. • If a private room is not available, place the resident in a room with a res- ident who has active infection with the same microorganism but with no other infection (cohorting). • A notice will be placed outside the room requesting that everyone report to the nurses’ station before entering the room. 2. Mask In addition to standard precautions, all staff must wear a mask when working within 3 feet of the resident. 3. Resident Transport Transport the resident from the room only for essential purposes. • Whenever possible, have diagnostic tests and procedures done in resi- dent’s room rather than transporting the resident to other departments.

Nursing Management of Infections 107 • When resident must be transported out of the room to other areas, the resident is to wear a mask to minimize dispersal of droplets. The receiv- ing department should be notified of the droplet precautions. 4. Education • Educate the resident and alleviate resident’s concerns about droplet pre- cautions. • Inform resident to cover mouth and use tissues when coughing or sneez- ing; teach the resident the proper disposal of used tissues. D. Contact Precautions In addition to standard precautions, use contact precautions for a specified resi- dent known to be or suspected of being infected or colonized with important mi- croorganisms that can be transmitted by direct contact with the resident (hand, or skin-to-skin contact that occurs when performing resident-care activities that re- quire touching the resident’s dry skin) or indirect contact (touching) with envi- ronmental surfaces or resident care items in the resident’s environment. 1. Resident Placement • All residents requiring contact precautions will be admitted to a private room. • Place a resident who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or en- vironmental control in a private room. • When a private room is not available, place the resident in a room with a patient who has active infection with the same microorganism, but with no other infection (cohorting). • When a private room is not available and cohorting is not achievable, consider the epidemiology of the microorganism and the relative risk to the other resident(s) occupying the same room when determining place- ment. 2. Gloves and Hand Washing • Wear gloves as outlined under standard precautions. • While providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microor- ganisms (e.g., fecal material and wound drainage). • Remove gloves before leaving the resident’s environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent.

108 Barton and Register • After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resi- dent’s room to avoid transfer of microorganisms to other residents or the environment. 3. Gown • Wear a clean, nonsterile gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, envi- ronmental surfaces, or items in the resident’s room. If the resident is in- continent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing, a gown should be used to protect clothing. • Remove the gown before leaving the resident’s room and discard. • After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorgan- isms to other residents or the environment. 4. Patient Transport • Limit transport of the resident from the room to essential purposes only. • If the resident is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment. No- tify the receiving department that the resident is on contact precautions. 5. Patient Care Equipment • When possible, dedicate the use of noncritical resident-care equipment to a single resident (or cohort residents infected or colonized with the same pathogen) to avoid sharing equipment with noninfected residents. • Equipment dedicated to a single resident for use during contact precau- tions that will not be discarded is to be disinfected before being used by another resident. • Handle, transport, and process used linen in a manner that will not con- taminate clothing and that avoids transfer of microorganisms to other residents or the environment. E. Antibiotic-Resistant Microorganisms Today, residents are becoming infected with antibiotic-resistant microorganisms more frequently than ever before. In LTCFs, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci are two of the most im- portant resistant pathogens encountered. Extensive discussions on these organ- isms are found elsewhere in this book (see Chapters 22 and 23).

Nursing Management of Infections 109 Because of the scarcity of private rooms, criteria must be developed for the optimum selection of appropriate room placement and roommates for the resi- dents diagnosed with infections caused by these resistant microorganisms. 1. Definitions Colonized. A resident is culture positive for the organism but exhibits no symp- toms or signs of infection. Infected. A resident is culture positive for the organism and exhibits symptoms and signs of infection (e.g., purulent drainage from a wound, elevated tempera- ture, productive cough, urinary frequency with pain or burning). Contained. • Wound. A draining wound is covered by an absorbent dressing that con- tains the wound drainage • Urinary. The resident has a Foley catheter or is continent. • Respiratory. The resident is competent to cover his mouth with tissues when coughing or sneezing and disposes tissues in a plastic bag. Uncontained. • Wound. Drainage from a wound is too profuse to be contained by a cov- ering dressing. • Urinary. The resident is consistently incontinent of urine. • Respiratory. The resident is confused and consistently coughs, sneezes, and expectorates without using tissues. Resident’s culture status. • It is known that the resident’s cultures are negative for resistant mi- croorganisms. • It is known that the resident’s cultures are positive for resistant microor- ganisms and the resident has an active infection. • It is known that the resident’s cultures are positive for resistant microor- ganisms, but the resident is exhibiting no symptoms or signs of active in- fection (colonized). • It is known that the resident is culture-negative at this time but has had a positive multiresistant microorganism culture in the past • It is NOT known if the resident has now or has had in the past, a positive culture for a multiresistant microorganism. 2. Risk for Acquiring an Infection with a Resistant Microorganism If a resident falls into any of the categories below, he or she is a greater risk for acquiring a colonization or infection with a resistant microorganism.

110 Barton and Register • Bed/chair confined • Poor functional status • Urinary incontinence (males) • Open wounds or pressure ulcers • Invasive devices present (e.g., Foley catheter, urostomy, colostomy, feeding tubes, tracheostomy, intravenous lines) • Frequent (or is currently on) antibiotic therapy • Prior infection or colonization with a resistant microorganism 3. Room Definition • Private. A single-bed room or a semiprivate room with no other resi- dent. • Cohort. Placing a resident who is infected in a room with a resident who is infected with the same organism but with no other infectious organ- ism. A colonized resident may also be placed in a room with another res- ident who is colonized with the same organism. Table 2 Guidelines for Room Placement of Residents with Antibiotic-Resistant Microorganisms Room type: Private room Cohorting* With a resident With a resident new admission at low risk at high risk Resident culture Yes Yes, if new resident Yes Yes, if new resident negative has been assessed has been assessed Resident culture positive for as a low risk as a low risk infection Yes Yes Yes, if no other No Resident culture positive, no placement is infection, colonized available Resident culture Yes Yes Yes No negative now, culture positive in Yes Yes, if new resident Yes Yes, when no other the past is now assessed placement is as a low risk available and Resident culture resident is assessed status unknown Yes Yes, if new resident Yes as a low risk has been assessed as a low risk Yes, if new resident has been assessed as a low risk * Residents, each colonized or infected with a different resistant microorganism, for example, methicillin- resistant Staphylococcus aureus and vancomycin-resistant enterococci, respectively, should never be cohorted.

Nursing Management of Infections 111 • A room with a resident at low risk for acquiring an infection with a re- sistant microorganism. • A resident who has never had colonization from a resistant mi- croorganism. • A resident who has no invasive devices present. • A resident who is not confined to bed or wheelchair. • A resident who has no incisions or open wound. • A room with a resident with high risk for acquiring an infection from a resistant microorganism (see earlier discussion). Guidelines for room placement are described in Table 2. The benefits of iso- lating residents should always be weighed against the potential adverse effects on psychosocial status and quality of life. V. EDUCATION A. Infection Control Professional Long-term care facilities should make available educational opportunities to ex- pand knowledge in infection control practices for the staff member designated to perform the duties of infection control professional (ICP). The APIC frequently offers, throughout the country, educational training in basic infection control prac- tices. This program includes topics of surveillance methodology, basic microbiol- ogy, immunology, infectious process, infection-control precautions, and outbreak investigation. This will provide the staff member a good foundation for establish- ing an infection control program and setting up surveillance protocols. Advance training and certification programs are also available from APIC for the ICP. Membership in APIC affords the opportunity for networking with other ICPs in an exchange of ideas and problem-solving. Also, subscriptions to periodicals or Internet links give access to information on infection control practices. This in- formation is essential to maintain updated and current information on changes and trends in the field of infection control (10). B. Staff Education The ICP should provide ongoing infection control education for all levels of LTCF staff, both for the direct caregivers (nurses, nursing assistants, therapist, etc.) and ancillary staff (maintenance, dietary, housekeeping, etc.) Education should include information on: • How infections are transmitted • What makes residents susceptible to infections • Standard and transmission-based precautions

112 Barton and Register • Antibiotic-resistant microorganisms • The importance of basic hand washing • How the infection control program functions The ICP must be aware of staff concerns related to caring for residents with infections. For example, a resident with a Foley catheter is newly diagnosed with urinary tract infection with MRSA. The caregivers are concerned that they have been caring for this resident and the resident has not been on contact precautions. Additional training in standard precautions, non-resistant staphylococcal versus MRSA infections, and the role of susceptibility in acquiring infection may be re- quired to alleviate staff concerns. C. Tips on Nursing Care for Infection Prevention 1. Proper Foley catheter insertion using aseptic technique and proper/fre- quent Foley catheter care will assist in decreasing the number of urinary tract in- fections (12). Adequate fluid intake should be maintained, when not medically contraindicated, to help prevent urinary tract infections. 2. Preventive measures for decreasing the development of pressure ulcers and related infection complication include the following: • Schedule toileting for incontinent residents. • Turn schedule/pressure relieving mattresses for residents at risk while in bed. • Elevate heels off the mattress with pillows. • Position devices in bed, recliners, wheelchairs. • Maintain good nutritional and fluid intake. • Use lift sheets and two employees when changing resident’s position. • Adhere to a position change schedule when a resident sits in a chair, re- cliner, or wheelchair. 3. When a resident is on antibiotic therapy, offering yogurt or buttermilk may help prevent yeast infections and assist in maintaining normal bacterial flora. 4. A policy that residents do not have contact with staff members who are diagnosed with an infection should be enforced. Infected staff members should also use appropriate protective equipment, (e.g., mask when infected with a res- piratory infection) to safeguard the residents. 5. Employees should use gait belt when transferring, repositioning in a wheelchair, and ambulating residents to decrease the chance of skin tears or lac- erations that would put the resident at risk for infection. 6. An active immunization program for current residents, new admissions, and employees should be implemented (13). Although these types of programs may be expensive, it will be more costly to treat multiple active infections.

Nursing Management of Infections 113 a. Residents • Annual influenza vaccination should be administered after the last week in October to assure continued antibody levels throughout the “flu” season. • D/T (diphtheria/tetanus toxoid) booster when source of skin tears, lacerations, or puncture wounds is unknown and resident has not had a booster in more than 10 years. • D/T booster every 10 years when no major injuries have oc- curred. • D/T booster in the case of a major injury if no booster adminis- tered in more than 5 years. • Pneumococcal vaccine for all new residents without prior im- munization. b. Staff • Measles, mumps, and rubella vaccine for all employees born af- ter December 31, 1956 if they are unable to provide verification of prior immunization • Influenza vaccine annually • Hepatitis B vaccination 7. Tuberculin skin testing with purified protein derivative (PPD) is rec- ommended for all new residential admissions using a two-step Mantoux method. New staff, staff exposed to active tuberculosis, and staff as part of their annual em- ployment examination should receive a PPD skin test. VI. CONCLUSION The staff will need continuing education on changes that occur with aging and how symptoms and signs of infection may manifest differently in the geriatric population. The staff should understand what is “normal” for each resident under their care. The nurse must give careful attention to the culture and sensitivity reports to assist the physician in decreasing the inappropriate use of antibiotics. The staff needs to con- tinue to improve resident assessment skills to identify the presence of infection and to work on effective communication skills to relay this information to the physician and other personnel, as appropriate. Knowledge of and adherence to infection con- trol procedures and practices are essential in preventing infections and outbreaks. REFERENCES 1. U.S. Department of Health and Human Services, Health Care Financing Administra- tion. Medicare and Medicaid requirements for long term care facilities. Federal Reg- ister September 26, 1991; 56:48826–48879.

114 Barton and Register 2. Smith PW, Rusnak P. APIC guideline for infection prevention and control in the long-term care facility. Am J Infect Control 1991; 19(4):198–215. 3. McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Pep- pler C, Rivera A, Schollenberger DG, Simor E, Smith PW, Wang EE-L. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991; 19(1):1–7. 4. Christensen PJ, Kenney JW. Nursing Process Application of Conceptual Models, 3rd ed. St. Louis, The C. V. Mosby Company, 1990. 5. Shua-Haim JR, Ross S. Pneumonia in the elderly. Clinical Geriatrics (on-line). Avail- able at: http://www.mmhc.com/cg/articles/CG0001/shua.html. 6. Fune L, Shua-Haim JR, Ross JS, Frank E. Infectious diseases in the elderly. Clinical Geriatrics (on-line). Available at http://www.mmhc.com/cg/article/CG9803/Shua- Haim.html. 7. Rajagopalan S, Moran D. Infectious disease emergencies in older adults. Clinical Geriatrics (on-line). Available at: http://www.mmhc.com/cg/article/CG101/ raja.html. 8. Garner J. Guideline for isolation precautions in hospital. Infect Control Hosp Epi- demiol 1996; 17(1):53–80. 9. Barrs AW, Fahey P. Infection control across the board. Nurs Homes Long Term Care Management 2000; 49(11):38–43. 10. Pritchard V. Joint Commission standards for long-term care infection control: Putting together the process elements. Am J Infect Control 1999; 27(1):27–34. 11. Smith PW, Rusnak PG. Infection prevention and control in the long-term-care facil- ity. Am J Infect Control 1997; 25(6):488–512. http//www.nih.gov/ninr/vol3/Infec- tion.html. 12. Fune L, Shua-Haim JR, Ross JS, Frank E. Infectious disease among residents of nurs- ing homes. Ann Long-Term Care 1999; 7(11):410–417. Available at: http://www. mmhc.com/nhm/articles/NHM9911/shuahaim.html. 13. Drinka PJ, Gravenstein S. Management of influenza in the nursing home. Ann Long- Term Care 2000; 8(9):23–30.

9 Establishing an Infection Control Program Janet Nau Franck Consulting Professionals, Inc., St. Louis, Missouri Elizabeth Owens Schwab BJC Health System, St. Louis, Missouri David W. Bentley Saint Louis University School of Medicine, and St. Louis VA Medical Center, St. Louis, Missouri I. INTRODUCTION In one’s lifetime, the potential for entering a long-term care facility (LTCF) con- tinues to increase along with its risk. It is estimated that more than 40% of persons aged 65 and older will require an LTCF, such as a skilled nursing facility, some- time during their lifetime. Because of their multiple underlying risk factors, the possibility of infection increases, but chronic illness, dementia, overuse of antibi- otics, and lack of diagnostic resources all contribute to the delay or inability to promptly recognize and treat infection (1). It is no surprise, therefore, that infec- tion control practices in LTCFs are being recognized as a critical component in the prevention and control of infections. This chapter provides practical guidelines for establishing and maintaining an effective infection control program in the LTCF, including useful practices and resources for the beginning infection control pro- fessional (ICP). A resource that provided much of the focus for this chapter was previously published (2) (see also Chapters 8 and 10.) 115

116 Franck et al. II. THE CASE FOR ESTABLISHING AND MAINTAINING AN EFFECTIVE INFECTION CONTROL PROGRAM A. Increased Infection Risk in the Elderly The increasing numbers of frail older persons requires that more care be provided in LTCFs such as nursing homes, especially skilled nursing facilities. Many of these residents are immunocompromised because of comorbidities, medications, and functional disabilities. These residents require comprehensive infection con- trol programs targeted toward the high risks of infection imposed by the special conditions of the LTCF and the residents’ own susceptibilities. High employee turnover rates and multiple facility priorities continually thwart effective infection control programs. Such challenges undermine even the best, most organized in- fection control effort. The nature of the LTCF resident’s immune suppressed state, combined with the challenges of day-to-day facility operations require constant vigilance toward infection control and prevention. B. Regulatory Requirements 1. Mandated Federal, State, and Local Requirements Mandated requirements from federal regulatory and advisory agencies, such as the Health Care Financing Administration (HCFA) (3) and the Occupational Safety and Health Administration (OSHA) (4), require that LTCFs comply with their written directives as outlined in their survey manuals. These requirements reflect a number of infection control issues. The OSHA Bloodborne Pathogen Standard (4) focuses primarily on minimizing exposure of bloodborne pathogens to health care workers, for example human immunodeficiency virus (HIV) and hepatitis B. Additionally, regulatory requirements by HCFA and the Omnibus Budget Reconciliation Act (OBRA) (5) address federal regulations that mandate that LTCFs establish prevention and control of infections associated with ad- mission to, or employment in, such a facility. It is most helpful to take a core set of requirements from these and other agencies and adapt them to the LTCF’s needs. The infection control program also needs to be compliant with local and state requirements that relate to the prevention and control of infections in LTCFs (6). This information can be obtained from an LTCF administrator or the state De- partment of Health. Many of these agency requirements are similar. For example, recommendations overlap in addressing policies regarding (1) admissions, (2) tu- berculin testing of residents, (3) employee health, (4) immunizations, (5) HIV-in- fected residents, and (6) infection control (6). It is essential to focus on the adap- tation of standards applicable to your facility’s needs to obtain licensure and comply with regulatory requirements.

Establishing an Infection Control Program 117 2. Voluntary Organization Requirements An example of voluntary organization requirements is the Joint Commission on Accreditation of Healthcare Organization (JCAHO), which publishes long-term care standards (7). These standards address a number of infection control issues, and compliance with these standards is necessary to attain JCAHO accreditation. An additional resource is published by the American Health Care Association (8). III. ESSENTIAL ELEMENTS OF AN EFFECTIVE INFECTION CONTROL PROGRAM A. Program Elements 1. Oversight Committee A committee with oversight responsibilities for an infection control program should be organized to provide the necessary authority and decision-making func- tions for an effective program. Although the committee may meet only as needed or be combined with the work of other committees, such as quality improvement, pharmacy review, or occupational health and safety, its purpose should be to over- see the process of reducing the risks of facility-acquired infections in residents and healthcare workers (7). The committee also serves to review and analyze surveil- lance data and collectively approve recommendations for ongoing prevention and control measures. It acts as the enforcing body within the organization for contin- uous application of good infection control practice throughout the facility and takes action, as necessary, to implement emergency control measures during an outbreak. The oversight committee should have appropriate authority from the admin- istrative and medical leadership. The committee, therefore, should include the medical director, the director of nursing, the ICP, and a representative from each of the following areas: nursing staff, administration, and other clinical departments such as rehabilitation, dietary, pharmacy, housekeeping/maintenance, and others. If the ICP and quality improvement professional are not one and the same, the group should also include the individual responsible for coordinating the facility’s performance improvement process (7). The essential elements of an effective in- fection control program in LTCFs have been identified (8–10) and include the over- sight committee and other elements shown in Table 1 and described below. 2. Infection Control Professional One author describes the ICP as the “eyes, ears and feet of the infection control program” (11). The ICP assesses, gathers information (surveillance), and moves throughout the facility not only to gather information but to implement or enhance

118 Franck et al. Table 1 Essential Elements of an Effective Infection Control Program in the Long-Term Care Facility Oversight committee Infection control professional Infection control program elements Infection surveillance Infection control interventions Outbreak investigation and control Education for employees, residents, and visitors Policy and procedure development Employee health program Resident health programs Antibiotic resistance management Antibiotic utilization and review Effective interdepartmental partnerships Disease reporting to public health departments existing prevention and control measures. The designated person responsible for coordinating the infection control program is usually a staff nurse. It is ideal for this person to be a registered nurse and work closely with the director of nursing. Appropriate delegated authority, clinical background, infection control training, and nursing’s multiple roles in the LTCF are important variables in the ultimate success of the ICP role. Each of these factors plays a vital role in how the ICP will function on a day-to-day basis and consequently, may largely contribute to, or detract from, the efficacy of the overall infection control program. The LTCF must wholly support the ICP and the efforts for surveillance and infection prevention. Without this support, access to important information may be blocked, partnerships with other departmental managers may fail, and most importantly, the facility may not receive vital data on facility-acquired infection, which will be needed to improve resident care. It is important that the ICP have a clinical back- ground—ideally in nursing, preferably in caring for the elderly. Knowledge of mi- crobiology and a general understanding of antibiotic use are also helpful. Infec- tion control training and exposure to available resources are the foundations of the ICP’s successful job role. Basic knowledge of infection control standards, meth- ods of surveillance, and requirements for an effective program can be obtained via textbook, journal, and Internet access. To access these resources, the professional must be allocated the time and financial resources to purchase or borrow from a medical library such items and digest the information they offer. Several websites for infection control information have been included at the end of this chapter. To use these websites, the ICP must have access to a personal computer with Internet connection and, again, the time to review the information. Several courses given

Establishing an Infection Control Program 119 by national or regional groups are also available. The Association for Profession- als in Infection Control and Epidemiology (APIC) offers a training course for hos- pital and LTCF ICPs (202-296-2742). The Missouri Chapters of APIC offer the “Essentials of Infection Control Annual Conference” yearly in mid-Missouri (573-893-3700), and the Nebraska Infection Control Network offers a basic train- ing course specifically for LTCF ICPs (402-552-2360). 3. Infection Surveillance a. Endemic Rates. Routine infection surveillance is the cornerstone of the in- fection control program. The facility should use surveillance data to drive infec- tion control interventions and decision-making for infection prevention. If surveil- lance data are given to clinicians and staff on a regular basis, the information can serve to initiate improvement in resident care. It can also be used to display suc- cesses in infection rate reduction as a means to reach administrators or others who allocate resources for infection control and prevention. Essential elements of surveillance are described in Table 2. The surveillance program should include a consistent and systematic data collection process with written definitions. The population(s) of interest, for example, residents with Fo- ley catheters or pressure ulcers, should be defined. Data should then be collected and consolidated for routine but meaningful reporting and evaluation. Analysis and interpretation should be conducted regularly. Surveillance data should be used Table 2 Essential Elements of Surveillance for Infection Control Element Description Comment 1. Data collection Systematic data collection Defined numerator/denominator 2. Documented Documented surveillance surveillance process Written process with Frequent data review/swift written definitions 3. Review and analysis control measures as appropriate Include type of infection 4. Rate calculation and and date of onset reporting Periodically calculate and report rates (monthly, Use standardized rate 5. Data used for IC quarterly) calculation/1000 intervention planning resident days Use surveillance data to drive IC efforts Short-term planning and long-term priority setting Abbreviation: IC, Infection control. Adapted from Ref. 9.

120 Franck et al. in the short term to plan immediate infection control measures or educational pro- grams, detect epidemics, or identify individual resident problems for intervention or treatment. For the long term, surveillance data can be used to determine ongo- ing educational needs, resource allocation for upcoming years, and objectives for infection control planning in subsequent years. Definitions for LTCF-acquired infection. Although standard definitions for nosocomial infection in acute care have long been available (12), no similar set of definitions has been validated for LTCFs. A panel of experts published a set of LTCF-acquired infection definitions by body site established by consensus con- ference methods that have been widely adopted by LTCF infection control pro- grams (13) (see Appendixes). The definitions should be written and kept in a cen- tral location such as the infection control manual or on personal computer disk so that the ICP or other members of the organization can access them at any time. This becomes particularly important in the LTCF where turnover rates can be high and new individuals will frequently need to be trained on the surveillance process. Data collection reporting and rate calculations. Ideally, the ICP will use stan- dardized data collection methods and tools to obtain surveillance information. This approach, along with the use of specific definitions, helps assure consistency of data collection and analysis for comparison over time. Sources for obtaining in- fection information are described in Table 3. The ICP’s presence in the resident care areas shows staff that infection control is important and that administration supports infection control and values adherence to good infection control practice. Infection rates are used to provide a common basis for entering surveillance data. Rates require a numerator, or number of nosocomial infections in a given pe- riod, for example, the number of urinary tract infections in July, and a denomina- tor, which in LTCFs is the population at risk or total number of resident-days in July. For example, if the LTCF had an average daily census of 140 for July and 14 new infections were detected, the rate would be 14/140 ϫ 31 ϫ 1000 ϭ 3.2 in- fections per 1000 resident-days. For further details on data collection, reporting, Table 3 Sources for Infection Information Patient-based Resident assessment, hall rounds, staff communication, medical record, X-ray reports, Kardex review, temperature logs, medication/pharmacy records/treatment logs Laboratory-based Microbiology reports, antimicrobial susceptibility reports Other departments or agencies Admissions/social work/rehabilitation, physician offices or outpatient clinics, home care/home infusion agencies, acute care facilities, state and local health departments

Establishing an Infection Control Program 121 and rate calculations and their use in infection control programs in LTCFs, other reference sources are available (11). b. Epidemic Rates. Surveillance data provide the basis upon which the ICP may identify an epidemic or outbreak of a particular infection type. Day-to-day collection of surveillance data allows the opportunity for early detection of such epidemics. Epidemic rates are infection rates of a particular type or organism that are higher than expected. For some organisms, one or two cases may be consid- ered an epidemic, for example, hepatitis A or group A Streptococcus. For others, several isolates with similar antibiotic susceptibility patterns or other common features, such as common body site or common resident location, must be present to initiate outbreak or cluster investigation. Examples of the latter include methi- cillin/oxacillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE). 4. Outbreak Investigation and Control As discussed above, an outbreak or epidemic is an occurrence of similar infections at a rate that exceeds the rate normally expected in a given location and period. Al- though most facility-acquired infections in LTCF are endemic, a portion do occur from outbreaks. Aggressive detection and control are important because of poten- tial morbidity and mortality to residents and staff, subsequent cost of investigation and treatment, and public relations difficulties often related to outbreak occur- rence. An outbreak can be one case of a disease of unusual virulence or public health importance, as noted above. For less virulent organisms, an outbreak can be defined as three or more cases related by time, place, and person within the same population (see also Chapter 10). Knowing the usual endemic baseline rates, the ICP can also suspect an out- break by noticing infection rates equal to 2 1/2 times above the usual rates. Some experts in infection control in LTCFs have suggested identifying outbreaks by threshold testing, which uses a simplified table of binomial distributions to calcu- late probabilities of infection frequency at selected endemic levels (mean number of infections per month) and compares these probabilities to observed infection frequency. This method is straightforward and does not require knowledge of statistics, special computer software, denominators, or calculation of rates (14,15). Table 4 lists the appropriate steps to outbreak investigation in a LTCF. 5. Education for Employees, Residents, and Visitors Infection control inservice education should be provided by the ICP and depart- ment supervisors to all employees on a timely basis, particularly during their ori- entation. Documentation of training should reflect the dates, times, attendees, and evaluations. Topics should reflect the goals identified in the infection control pro-

122 Franck et al. Table 4 Steps to Outbreak Investigation in a Long-Term Care Facility Request help, notify state and local health departments Control the known Determine case definition Compile line list of initial cases; seek additional cases that fit definition Initiate additional/extend original control measures to more areas based on case finding Inform and educate staff, residents, families Check for daily new cases until occurrences cease Present follow-up report to administration and health department: compile all documentation (epidemiologic curve, line list, description of control measures) gram plan and concerns identified from surveillance data. For example, before the influenza season, presentations should identify symptom recognition, transmis- sion of the infection, vaccination and chemoprophylaxis policies, the importance of hand washing and other hygienic practices, appropriate waste disposal, bagging at the point of contact and universal precautions. Coordinated effective educa- tional programs will result in improved infection control activities (8,16,17). Infection control-related education of residents and visitors can help reduce the risk of transmission of pathogens by resident-to-resident or resident-to-visitor contact and decrease the level of stress for both parties. For example, the APIC- Orange County Patient and Family Education Task Force has developed a series of 20 education pamphlets that can be accessed by computer disk and customized for individual LTCF needs. These educational pamphlets can be adapted to en- hance resident and family understanding of how to minimize the transmission of infection. These could be translated to other languages when such barriers are a concern. For additional information, see the Appendix at the end of this chapter. 6. Policy and Procedure Development An important aspect of the infection control program is the development, review, and updating of policies and procedures (P&Ps). This requires the ICP to be avail- able to make rounds, provide educational input, and monitor compliance of P&Ps to ensure adherence. Many areas should be considered when establishing infec- tion prevention and control. Resources are available to assist in the development and writing of these P&Ps (9,18) (see also the Appendix at the end of this chapter for additional sources). Table 5 lists a good sampling of P&P topics to include. The P&Ps need to be clearly written, updated, and referenced on a timely basis. Staff should be oriented to them as they pertain to the performance of their job. Departmental supervisors should be consulted in the drafting of their P&Ps and present them to the infection control committee for final approval. These P&Ps require regular review and approval for example, every 2 years. An inter-

Establishing an Infection Control Program 123 disciplinary approach is essential when developing these P&Ps, including admin- istration, nursing, medical, and support services/departments. The infection con- trol committee minutes should document this approach for accreditors and serve to track their review and expansion. Policies and procedures are critical to the success of the program. They serve as the basis for procedural inservices, staff performance, and they demonstrate competency and program evaluation. As a re- source, they should be closely aligned with the mission and vision of the organi- zation to promote a team focus (19). 7. Employee Health Programs The health of the employee is important to the delivery of safe care for all resi- dents. This includes the requirements that employees should be hired without communicable diseases (3) and are protected from occupational exposure to bloodborne pathogens (4). Guidelines for infection in hospital personnel are avail- able (20) and are generally adaptable to the LTCF (9). Other important issues that are not mandated but on which employees should be instructed are the sick and accident policy and post-exposure follow-up or preventative programs for certain infections, such as HIV, hepatitis B virus, and scabies or lice (9). Tuberculosis screening and education is a key element in the employee health program. Major components for instruction by the ICP include the two-step tuberculin skin test, interpretation of test results, follow-up of posi- tive skin tests, and staff awareness of their symptoms and signs that may represent Table 5 Sample List of Policies and Procedures for Infection Control in Long-Term Care Facilities Role of administration Hand washing Universal precautions/isolation Housekeeping, e.g., cleaning processes, waste disposal, and environmental surveillance Laundry, e.g., handling of soiled linen Dietary, e.g., food preparation and cleaning Rehabilitation services, e.g., physical therapy, occupational therapy Respiratory therapy, e.g., humidifier cleaning Employee health, e.g., tuberculosis screening and vaccinations and leave of absence Admission to the long-term care facility Transfer to an acute care facility Vaccination history, e.g., influenza, pneumococcal, and tetanus Management of residents with infections Infection surveillance and data collection Outbreak identification, investigation, and control Review antibiotic prescribing

124 Franck et al. active tuberculosis pulmonary disease (21). Employee vaccination programs should include influenza, hepatitis B vaccine, varicella, and hepatitis A virus, in certain circumstances (9). (See other chapters in this book relevant to these topics for further details). Organizations such as APIC and health departments can pro- vide literature, media material, and “tool kits,” that is, work sheets and educational aids, to further promote the understanding of and compliance with these chal- lenging employee health issues (see also the Appendix at the end of this chapter for these sources). 8. Resident Health Program Residents need to be screened on admission to the LTCF to assess their risk for transmitting an infection, as well as their need for preventive interventions to re- duce their risk for contracting infection (22). A major component of a resident health program is immunizations for influenza, pneumococcal disease, and tetanus (9) (see Chapter 20). In addition, all residents on admission should un- dergo tuberculin skin testing and a follow-up chest X-ray if the skin test is posi- tive or the patient is symptomatic (21) (see Chapter 15). Other interventions should be targeted toward the prevention of urinary tract infections, skin and soft tissue infections, and aspiration pneumonia (9) (see chapters on these topics in this book). 9. Antibiotic Resistance Antibiotic resistance is a major concern in LTCFs. Residents most likely to de- velop infections caused by resistant organisms are those with wounds such as pressure ulcers, underlying chronic diseases, poor functional status, invasive de- vices such as urinary catheters, and prior antibiotic therapy. Because these resis- tant organisms may enter the facility through colonized or infected hospital patients and become endemic, strategies must be established by LTCFs to control their spread. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread (23). Strategies to control transmission of antibiotic-resistant pathogens in LTCFs is limited, and strategies used in hospitals often are inapplicable. The Society for Healthcare Epidemiology of America (SHEA) position paper (23) pro- vides a good discussion of this problem. In addition, Section III of this book pro- vides several chapters on antimicrobial resistance in LTCFs. 10. Antibiotic Utilization An important contributing factor to the growing problem of antibiotic resistance is the overusage and inappropriate prescribing of antibiotics in LTCFs. To im- prove antimicrobial use, a second SHEA position paper (24) recommended that LTCFs develop and implement several control measures. Infection control pro-

Establishing an Infection Control Program 125 grams should include antibiotic utilization review of the antibiotics that are being prescribed in the LTCF to help limit the potential for the spread of resistant or- ganisms. Others have recommended that the key data to collect include: (1) inci- dence (number of antibiotic courses started per 1,000 resident-care days) and (2) antibiotic utilization ratio (ratio of number of antibiotic-days to number of resi- dent-care days). Because the costs of antibiotics are often easily available from ad- ministration and pharmacy and appear to reflect overall antibiotic use, data on an- tibiotic costs per resident-care-day can serve as an alternative to the intensive utilization review items noted (25) (see Chapter 11). 11. Effective Partnerships a. Alliance with Administration, Medical Director, and Director of Nursing. Before establishing a new (or enhancing an existing) infection control program, the facility administrator must fully appreciate the importance of infection control. Not only must the administrator understand the increased infection risk for the resident, but also the increasing regulatory requirements for infection control as a condition of participation in Medicare. To educate the administrator on the value of an excellent infection control program will require the full support and promotion by those who first see it as valuable: the medical director (MD) and the director of nursing (DON). Depending on the LTCF, the education process for the administrator by these healthcare professionals may require first demonstrating the need for an ICP. Collaboration between the MD and DON or ICP is critical in making the process a success. After the MD/DON team has educated the administrator on these compo- nents, the administrator should be presented with a proposal for resources needed. Each program should include several essential elements for success, for example surveillance program, isolation policies, employee education, and others as noted in Table 1. The overall program will require several resources to ensure its suc- cess. The key resources include: an ICP with knowledge of or supporting re- sources for fundamentals of infection control, Internet access and, if possible, ap- propriate computer software and hardware to manage a surveillance database, adequate workspace, and sufficient medical and administrative support to influ- ence others in the facility, even without having direct authority over them. b. Alliance with Department Manager/Supervisors/Nursing. In all areas, the ICP must communicate closely with staff to ensure that they have the knowledge, expertise, and supplies necessary to comply with standard precautions, isolation practices, aseptic technique, and other problem-specific issues. An effective strat- egy to identify unsafe practices is to perform walking rounds, document issues of noncompliance, and distribute the findings to the individual department man- ager/supervisors. Noting practices such as breaks in aseptic technique is essential in recognizing opportunities for improvement, such as wearing gloves inappro-

126 Franck et al. priately or not bagging and knotting bags of soiled items at the point of use. Is there an availability of personal protective equipment (PPE) in soiled utility rooms when cleaning reusable medical devices? Does the trash that is placed in biohaz- ardous waste containers meet the definition of being blood “soaked or caked,” as mandated by OSHA? Is the facility paying for additional poundage of regular trash to be transported by special waste handlers? Are food products labeled and dated, and are refrigerators being cleaned after spillage on a routine basis? If not, education can act as a critical means of modifying behavior. c. Quality Improvement. Long-term care facilities have continued to empha- size quality improvement (QI) processes. There are a number of similarities be- tween QI and infection control programs. Both use methods to collect data, then search for adverse outcomes or risk-reducing strategies. Both programs demon- strate the value of education to change behavior and both perform follow-up eval- uations to determine if outcomes have improved. Infection control continues to be recognized as a performance improvement process due to the analytic process of collecting surveillance data, identifying areas of concern, and recognizing oppor- tunities for improvement. For this reason, many LTCFs have used the QI com- mittee meetings as a successful means of discussing and documenting infection control program activity (26). d. Environmental Hygiene. The LTCF must be monitored for cleanliness and proper maintenance because residents may often soil with body secretions and dis- charges with which the physical environment they come in contact. This can then serve as a reservoir for spreading infections to other residents and staff. These housekeeping policies must delineate the process and persons responsible for cleaning and disinfecting the environment. Cleaning schedules need to be closely followed, ensuring that cleaning products are facility-approved and dilutions are appropriate and standardized. Hand-washing facilities should be conveniently lo- cated and accessible to all staff. Insects and rodents must be eliminated and pre- vented from gaining access to the LTCF. Maintenance also plays a vital role in as- sessing and maintaining safe plumbing and ventilation systems of the facility. For example, their policies should indicate that air filters are changed routinely to avoid contaminating the environment or themselves. For laundry services, the ICP needs to monitor that bagging of linens at the site of use, that clean linens are covered, and that carts are cleaned between uses. In the laundry, separate areas must be designated for clean and soiled items. Phys- ical therapy equipment, especially hydrotherapy equipment, should be disinfected regularly and anytime there is visible soiling with bloody fluids. In food service, because of the risk of foodborne illnesses, it is important that the food preparation and services environment be clean and strict attention given to food handlers. The infection control program, with support from risk management, maintenance, and housekeeping, should establish and monitor policies and procedures for disposing

Establishing an Infection Control Program 127 of infectious or other waste materials, as defined and regulated by federal, state, and local regulations, including OSHA regulations (4), to minimize cost and oc- cupational exposure risk to healthcare personnel (27). e. Admissions/Social Worker. Admissions and Social Work have key roles in facilitating the transfer of patients from the hospital to the LTCF, with special em- phasis on infection control issues. The admission process should include clear and accurate information regarding the infection control risks of the patients before their transfer to the LTCF. For example, the transferring hospital facility should notify the LTCF regarding a patient harboring an antibiotic-resistant organism, the results of tuberculin skin testing, or other conditions for which additional precau- tions should be considered. All employees need to be reminded of the importance of confidentiality, whether the infection is HIV or MRSA. It is helpful for hospi- tals and LTCFs to formalize joint transfer agreements in advance to expedite pro- cesses and clarify policies. Of course, transfer of residents to hospitals require that equally clear and accurate infection control-related information be transmitted to the hospital prior to transfer. IV. BARRIERS TO ESTABLISHING AN EFFECTIVE PROGRAM Despite the LTCFs best efforts to create an effective infection control program, most facilities face formidable barriers in maintaining the program. The compli- cated work of resident care is strenuous and fast-paced, often leading to high turnover rates even among LTCF administrators, DONs, and ICPs. This necessi- tates frequent retraining and resecuring of infection control resources. Direct res- ident care staff also turnover quickly, which presents education challenges on a daily basis. Because many LTCFs are small (fewer than 200 beds), the ICP is of- ten assigned multiple roles. Although not unimportant, these other responsibilities may serve to distract the ICP from constant focus on infection surveillance and control measures. Other barriers include lack of infection prevention and control training, lack of necessary resources to implement an effective program and perhaps, most im- portantly, lack of strong administrative or medical support in the form of true delegated authority. As described above, basic infection control training is the foundation of a successful ICP role and is often both inexpensive and easy to ac- cess. The ICP must, however, have the time and means to access such educational resources. Other necessary resources that may be lacking include: desk/office space, Internet access and, possibly, computer hardware and software, secretarial or data entry support, time away from resident care for staff to attend infection control inservice education, access to local/regional resources, and time to attend local and regional APIC meetings.

128 Franck et al. V. LOCAL, REGIONAL, AND NATIONAL RESOURCES A. Local APIC Chapter Becoming a member of a local chapter enables the ICP to take advantage of nu- merous products, services, and educational opportunities that are timely and state- of-the-art. Whether it is the cutting-edge training courses the ICP needs, informa- tion regarding practice standards, networking opportunities, information technology resources, or practice guidelines, becoming a member of a national in- fection control association such as APIC can initiate the ICP’s training and sup- port needs (see the Appendix at the end of this chapter for additional information). B. County and State Departments of Health Another important element of the infection control program is to submit re- portable diseases to the public health department. The ICP needs to know which diseases must be reported by law and the process most efficient to ensure complete and accurate reporting. Depending on the surveillance system established, the ICP needs to determine who will report diseases when the ICP is on vacation or not available. The reportable diseases are critical data to the public health depart- ments, which rely on this information to provide educational and laboratory ser- vices for program planning and development. The State Communicable Diseases section also can serve as valuable consultants and provide useful information on current clusters or outbreaks of infection control problems in other LTCFs in the same locale. C. APIC/SHEA Several professional associations provide significant resources to ICPs and LTCF staff. The Association for Professionals in Infection Control and Epidemiology provides a quarterly Long Term Care Newsletter, journal articles in the American Journal of Infection Control, and a Long Term Care Section that meets at annual conferences and provides resources accessible from their web site. The Society of Health Care Epidemiology of America has a Long-Term Care Committee and publishes in the journal, Infection Control and Hospital Epidemiology, helpful guidelines on pertinent infection control-related topics that are frequently seen in LTCFs (see the Appendix at the end of this chapter for websites). VI. PROGRAM EVALUATION AND IMPROVEMENT Developing an annual plan and an evaluation and improvement program can start the ICP’s efforts to maintain administrative support and confidence in the infec-

Establishing an Infection Control Program 129 tion control program. Because each facility is unique, every effort should be made to address concerns that are specific to one’s own LTCF. Risk factors, resident population, and the nature of the LTCF will determine the criteria used for pro- gram planning and evaluation (28). As long as the outcome invites an opportunity for improvement, the quality of care will be positively enhanced. An excellent tool to use when evaluating your program is the APIC toolkit, “Assessing and Devel- oping an Infection Control Program.” Although this was written with the acute care setting in mind there is little difference between the program processes and methods to evaluate the effectiveness of the LTCF program (see the Appendix for source information). APPENDIX Supplementary Reading List APIC Text of Infection Control and Epidemiology, 2000. APIC National Office, 1275 K Street NW, Suite 1000, Washington, DC 20005-4006. Can be ordered by phone: (202) 789-1890. Contains all current APIC Guidelines, State of the Art Reports, Po- sition Papers, Commentaries, CDC and OSHA Guidelines. Arias K (ed). Assessing and Developing an Infection Control Program in the Acute Care Setting (and adaptable to LTCF). Infection Control Tool Kit Series, 2000; APIC Na- tional Office, 1275 K Street NW, Suite 1000, Washington, DC 20005-4006. Can be ordered by phone: (202) 789-1890. Contains useful guidelines, sample forms, docu- ments and references. Benenson AS (ed). Control of Communicable Diseases in Man, 15th ed. 1990. American Public Health Association, 1015 Fifteenth Street NW, Washington, DC 20005. Lists infectious diseases with signs, symptoms, epidemiology, contagious periods and treatment. Heaton WH, Thayer NL. Infection Control Program: Policy and Procedure Manual (for LTCFs). National Health Publishing, 428 E. Preston St., Baltimore, MD 21202, tel. 301528-4000. Useful resource for developing an IC program. Patient and Family Education (Pamphlets) disk, APIC Orange County: APIC National Of- fice, 1275 K Street NW, Suite 1000, Washington, DC20005-4006. Can be ordered by phone. (202) 789-1890. Contains educational infection control pamphlets that can be customized. Selected Internet Websites Association for Professionals in Infection Control and Epidemiology (APIC) http://www.apic.org/ Center for Disease Control and Prevention (CDC) http://www.cdc.gov/ Occupational Health and Safety Administration (OSHA) http://www.osha.gov/ Society for Healthcare Epidemiology of America (SHEA) http://shea-online.org World-Wide Web Virtual Library: Epidemiology http://www.epibiostat.ucsf.edu/ epidem/epidem.html/

130 Franck et al. REFERENCES 1. Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for evaluation of fever and infection in long-term care facilities. Clin Infect Dis 2000; 31:640–653. 2. Smith PW. Infection control program organization. In: Smith PW (ed). Infection Con- trol in Long-Term Care Facilities, 2nd ed. Albany, NY, Delmar Publishers, 1994: 105–114. 3. U.S. Department of Health and Human Services, Health Care Financing Administra- tion. Medicare and Medicaid requirements for long term care facilities. Federal Reg- ister September 26, 1991; 56:48826–48879. 4. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to blood-borne pathogens: Final rule. Federal Register December 6, 1991; 56(235):64004–64182. 5. Omnibus Budget Reconciliation Act of 1987. Pub L No. 100–203, December 22, 1987, subtitle C, part 1, 4201:160–170. 6. Crossley K, Nelson L, Irvine P. State regulations governing infection control issues in long-term care. J Am Geriatr Soc 1992; 40:251–254. 7. The Joint Commission on Accreditation of Healthcare Organizations. Comprehen- sive Accreditation Manuals for Long Term Care. Chicago, IL, Joint Commission on Accreditation of Healthcare Organizations, 1998. 8. American Healthcare Association. Infection Prevention and Control for Long-Term Care Facilities: Handbook and Instructor’s Guide. Washington, DC, AHCA, 1995. 9. Smith PW, Rusnak PG. Infection prevention and control in the long-term care facil- ity. Am J Infect Control 1997; 25(6):488–512. 10. Rusnak PG. Long-term care. In: Pfeiffer J (ed). APIC Text of Infection Control and Epidemiology. Washington, DC, APIC, 2000:17-1–17–31. 11. Rusnak PG, Horning LA. Surveillance in the long-term care facility. In: Smith PP (ed). Infection in Long-Term Care Facilities, 2nd ed. Albany, NY, Delmar Publishers 1994, 10:117–130. 12. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for noso- comial infections. Am J Infect Control 1988; 16:128–140. 13. McGeer A, Campbell B, Emori T, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang EE-L. Definitions of in- fection for surveillance in long term care facilities. Am J Infect Control 1991; 19:1–7. 14. Mylotte JM. Analysis of infection control surveillance data in a long-term care facil- ity: Use of threshold testing. Infect Control Hosp Epidemiol 1996; 17:101–109. 15. Smith PW. Epidemic investigation. In: Smith PW (ed). Infection Control in Long- Term Care Facilities, 2nd ed. Albany, NY, Delmar Publishers, 1994:131–146. 16. Smith PW, Daly PB, Rusnak PG, Roccaforte JS. Design and dissemination of a multi- regional long-term care infection control training program. Am J Infect Control 1992; 20:275–277. 17. Daly PB, Smith PW, Rusnak PG, Jones MB, Guiliano D. Impact on knowledge and practice of a multi-regional long-term care facility infection control training program. Am J Infect Control 1992; 20(5):225–233.

Establishing an Infection Control Program 131 18. Rusnak PG, Boehle MC. Regulation, policies and procedures. In: Smith PW (ed). In- fection Control in Long-Term Care Facilities, 2nd ed. Albany, NY, Delmar Publish- ers, 1994:161–168. 19. Pritchard V. Joint commission standards for long-term care infection control: Putting together the process elements. Am J Infect Control 1999; 27:27–34. 20. Diekema DJ, Doebbeling BN. Employee health and infection control. Infect Control Hosp Epidemiol 1995; 16:292–301. 21. Centers for Disease Control. Prevention and control of tuberculosis in facilities pro- viding long-term care to the elderly. MMWR 1990; 39(No. RR-10):7–20. 22. Yoshikawa TT, Norman DC. Infection control in long-term care. Clin Geriatr Med 1995; 11:467–480. 23. Strausbaugh LJ, Crossley KB, Nurse BA, Thrupp LD. Antimicrobial resistance in long-term-care facilities. Infect Control Hosp Epidemiol 1996; 17:129–140. 24. Nicolle LE, Bentley DW, Garibaldi R, Neuhaus EG, Smith PW, and the SHEA Long- Term-Care Committee. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 2000; 21:537–545. 25. Mylotte JM. Antimicrobial prescribing in long-term care facilities: Prospective eval- uation of potential antimicrobial use and cost indicators. Am J Infect Control 1999; 27:10–19. 26. Smith PW. Infection control program organization. In: Smith PW (ed). Infection Con- trol in Long-Term Care Facilities, 2nd ed. Albany, NY, Delmar Publishers, 1994: 105–114. 27. Haberstich NJ. Infection control measures: The environmental reservoir. In: Smith PW (ed). Infection Control in Long-Term Care Facilities, 2nd ed. Albany, NY, Del- mar Publishers, 1994:211–216. 28. Smith PW. Infection surveillance in long-term care facilities. Infect Control Hosp Epidemiol 1991; 12:55–58.



10 Epidemiologic Investigation of Infectious Disease Outbreaks Chesley L. Richards, Jr., and William R. Jarvis Centers for Disease Control and Prevention, Atlanta, Georgia I. INTRODUCTION Infectious disease outbreaks in long-term care facilities (LTCFs) are common, can cause serious morbidity and mortality for residents, and can be time consuming to investigate and control. Epidemiologic investigation of these outbreaks can be as complicated as outbreak investigation in hospital settings, and yet fewer infection control resources are generally available in LTCFs. Despite these challenges, inter- disciplinary infection control programs that include infection control professionals (ICPs), administrators, clinicians (e.g., physicians, nurse practitioners, physician as- sistants), pharmacists, laboratorians, and nursing staff can prevent many infectious disease outbreaks and successfully control those outbreaks that do occur. This chapter will review the principles of epidemiologic investigation as they apply to outbreaks in LTCFs, review aspects of selected infectious disease outbreaks, and discuss approaches to their prevention and control. Although LTCFs encompass a broad range of facilities from nursing homes for the elderly to long-term psychiatric facilities, the focus of this chapter is on outbreak investi- gation in nursing homes for the elderly. Many of the recommendations contained in the chapter, however, can be adapted and used in other LTCF settings. II. CHARACTERISTICS OF LONG-TERM CARE FACILITIES (LTCFs) Long-term care facilities are an increasingly important site of medical care and drug prescribing for the elderly. More than 40% of adults in the United States will 133