Isolation a common conundrum in LTC
Rising acuity challenges "home" culture
The challenge of improving infection prevention is a formidable one, given such basic conundrums as how do you effectively isolate an infected or colonized resident who needs to move about and socialize for their overall health and well-being?
While isolation systems are a cardinal principle of infection control in hospitals, experts trying to develop guidance for long term care concede the "unique infection control challenge for the LTCF is the mobile resident, who may be confused or incontinent and serves as a possible vector for infectious diseases."1 On the other hand, the downside of isolation, including inactivity and desocialization, could make recovery difficult for the infected resident.
Such issues are under discussion at high levels because long term care is the top priority in the next phase of the Department for Health and Human Services (HHS) Action Plan to prevent health care associated infections (HAIS). The HHS has formed a multi-representative long term care working group to identify key action items, many of which are likely to address transmission of multidrug resistant organism (MDROs). While there is general agreement that acuity is increasing in long term care, there is also the longstanding culture of a home environment.
"One of our goals is to increase the research and understanding of transmission dynamics for MDROs within this kind of community," says Nimalie Stone, MD, MS, a member of the HHS long term care working group and a medical epidemiologist at the Centers for Disease Control and Prevention. "There is a culture change movement [aimed at] making nursing homes less institutional and more homelike. I think that is very appropriate. We know that a person's physical, mental, and emotional healing is quickened when they are in a social environment and engaging in activities."
That said, it is sometimes necessary to implement isolation measures to prevent transmission or fight an outbreak.
"There are definitely times when contact precautions, for example, are implemented for a resident who has an active Clostridium difficile infection," she says. "Most facilities have a protocol or policy in place for using transmission-based precautions for times when an individual resident may have a higher risk of shedding an MDRO, or in this case when their environment could become quite contaminated by infectious spores that could be readily transmitted."
However, the duration of time that contact precautions are in place may differ from a hospital, which may simply leave the patient in isolation depending on the length of stay. "In a nursing home, that doesn't really work," she says. "I would say most facilities have protocols, but they have to tailor them to achieve this balance."
- Smith PW, Bennett G, Bradley S, et al. SHEA/APIC Guideline: Infection prevention and control in the long-term care facility Am J Infect Control2008;36:504-35.