New era of infection prevention in long term
The challenge: 380,000 infection deaths annually
For years scarce data on health care associated infections in long term care has been extrapolated from small studies and published reports, but a new era of infection prevention is opening that may eventually produce the kind of benchmarking and national comparative HAI rates used in hospitals.
Indeed, the current situation in nursing homes is somewhat analogous to hospitals in the 1970s, when facilities began reporting infection data to the old NNIS system at the Centers for Disease and Prevention. That surveillance system grew into what is now called the CDC National Healthcare Safety Network (NHSN), which has added a nursing home reporting component on the CDC's new website on infection prevention in long term care. (http://www.cdc.gov/longtermcare/)
"The website is a really important first step for our promotion of HAI prevention in long term care settings," says Nimalie Stone, MD, MS, a medical epidemiologist specializing in long term care at the Centers for Disease Control and Prevention. "I think it is arranged in a way that will allow us to expand the content as we develop more long term care resources and guidance. It is similar to how NHSN evolved for acute care hospitals, and at this point it is just a voluntary reporting option — a tool for nursing home providers. The fact that we are seeing facilities getting involved and using the [surveillance] system is really exciting to us."
A variety of factors contribute to increased risk for infections in the elderly, including declining immune response, incontinence, poor hygiene, and dementia. "Breaks in the skin, wounds, dependence upon others for hygiene, use of catheters, and decreased nutrient and fluid intake also may increase risk," according to a new guide book on infection prevention in long term care by the Association for Professionals in Infection Control and Epidemiology (APIC).1
"The other thing that is changing drastically is our patient population," says Deborah Patterson Burdsall, MSN, RN-BC, CIC one of the authors of the APIC book and corporate infection preventionist for Lutheran Life Communities in Arlington Heights, IL. "We have about 500 residents and we have approximately 110 beds that are acute short-day rehabilitation. The average length of stay is about 20 days. These patients we have now in basically a quarter of our rooms are the same kind of patients that I was taking care of when I worked in a medical oncology cardiac step-down at an acute care hospital. Our patient population has changed and the acuity that we are dealing with is just like acute care."
Fledgling network reporting to NHSN
With the risk of infections clearly established, facilities participating in the fledgling long term care surveillance network are reporting multidrug resistant organisms and Clostridium difficile as picked up in "laboratory-identified events" that serve as a proxy for infections, Stone explains.
"This is a strategy that we have used in acute care settings for a long time — using microbiologic reports and a positive lab tests for C. diff, for example, as a proxy indicator for the burden of those infections in that facility," she says. "They are reporting the same multidrug resistant organisms that acute care hospitals are reporting to NHSN."
In addition, the participating nursing homes are reporting urinary tract infections (UTIs). "And it's all UTIs -- not just catheter-associated events — because there is a substantial burden of non-catheter [UTIs] in long term care populations," Stone says.
With reporting beginning last year, the goal is gradually expand the network over the next few years until about 5% of the nation's nursing homes are linked to the NHSN surveillance system.
"We are just starting to build out the surveillance and prevention infrastructure for these providers," she says. "We'll learn a lot working with them to see how we can move the needle on HAI prevention."
In addition to the surveillance component, the CDC website includes educational materials, tools and checklists specifically designed for preventing infections in long term care. The challenge is a formidable one, as the CDC estimates that 1 to 3 million serious infections and 380,000 HAI related deaths occur annually in the nation's 15,000 long term care facilities. While "zero infections" campaigns are common in hospitals — where the prevailing perception is that most HAIs can be prevented — it is an open question how many infections and deaths are preventable in long term care.
"That's a very good question that we really need more information and research in order to answer," Stone says. "The estimates of this problem are still often based on experiences in a small number of facilities. When you try to apply it across a spectrum of over 15,000 facilities you have to be careful about generalizing. But I will say this, there are groups like the Advancing Excellence in America's Nursing Homes, which has been working for many years on improving the quality of care."
Indeed, the Advancing Excellence group is a key partner on the CDC's new long term care website. The partnership between CDC and Advancing Excellence grew through a joint effort to prevent C. diff infections in nursing home residents. Adding considerable momentum to the effort, long term care particularly preventing C. diff infection (CDI) is now a top priority of the Department for Health and Human Services (HHS) National Action Plan to Prevent HAIs. Long-term care represents the third phase of the HHS plan, which began with hospitals in 2009 and then added ambulatory care settings.
"C. diff has gotten a lot of attention — appropriately so — because it is such a significant health care priority," Stone says. "It is the leading cause of acute diarrheal infection in nursing homes. Also the population cared for in nursing homes tends to be vulnerable to severe C. diff infections. So it is very relevant, and the prevention strategies that you promote for reducing C. diff infection also will positively impact the reduction of the emergence and spread of other resistant organisms."
For example, hand hygiene promotion, cleaning and disinfection of the environment and antibiotic stewardship programs can all reduce C. diff and other infections. Antibiotic stewardship efforts in particular, including limiting the frequent and prolonged use of broad spectrum antibiotics, are needed to preserve the patients commensal gut bacteria which help prevent C. diff emergence. (See related story, p. 30).
The HHS action plan estimates that more than half of all health care-associated [C. diff infections] are occurring in nursing homes, where reported rates are between 1.7 and 2.9 infections per 10,000 resident days.2 Moreover, recent data indicates that 75% of health care-associated C. diff is occurring in non-hospital settings, with a "substantial portion" of these infections occurring in long term care, the HHS notes. Thus it is critical to use antibiotics judiciously in the nursing home population, the HHS plan states.
CMS putting the heat on
On another federal agency front, the Centers for Medicare and Medicaid Services (CMS) is also stepping up oversight of long term care facilities, according to APIC. As noted in the APIC guide book, "the CMS Division of Nursing Homes is currently working with strategic partners to develop strategies to reduce preventable healthcare-associated infections. This means that the focus on infection prevention and control will increase. It is critical to have a systematic, evidence-based approach to preventing infections within long-term care."
Asked which areas the CMS is particularly focusing on, Burdsall says, "Antimicrobial stewardship and interfacility communication. Those are the two biggies."
Indeed, with CMS penalties now in place for excess hospital readmissions, communication between facilities about the status of residents and patients moving across the health care continuum has become particularly important.
"The way that CMS is modifying its payment structures is forcing interfacility communication which is a positive thing," says Burdsall.
In that regard, some 25 state collaboratives between hospitals, nursing homes and state public health departments are cited on the CDC website as evidence that connections across the health care continuum are growing stronger.
"These [collaboratives] are a critically important piece of improving communications and detection of problems in care transitions," Stone says. "Your prevention activities are going to be much more effective when you have all of the partners working in concert with one another."
In any case, CMS is forcing more than just interfacility communication, Burdsall notes, addressing a recurrent myth that nursing homes have long flown under the regulatory radar. That may have been the case at one time, but public outrage at nursing home conditions has been followed by increasing regulation and oversight over the years.
CMS is certainly enforcing the regulations that are currently required, citing F441 citations for infection control lapses observed in unannounced inspections. (See CMS questions, right) For nursing homes, ongoing readiness is a must.
"CMS inspectors showed up here two weeks ago at 7:30 in the morning on a Sunday," Burdsall says. "They come in and they hit the floors immediately. You have to be survey ready at all times."
The isolation conundrum
CMS inspectors may ask about residents under isolation precautions, raising a difficult, longstanding issue in long term care. "Restricting residents to their room when colonized or infected with certain organisms includes both advantages and disadvantages," APIC notes in the guide book. "Isolation, even for a brief period, may have unintended psychological risks such as depression, anxiety, and fear of healthcare personnel and may pose a greater risk of adverse events. Therefore, there must be a balance between the consequences of social isolation and the need to prevent the possible spread of disease within the LTCF."
The assessment should also include clinical risk factors such as wounds, indwelling devices, secretion containment, the ability to follow instructions, and personal hygiene. The least restrictive approach, including the use of a private room as available, that balances these multiple priorities should be used, APIC recommends.
The situation is reminiscent of the old restraint policies that were once widely used in nursing homes, Burdsall says. The original idea was to protect residents from falls, but the practice was abandoned when research indicated that restrained residents were more likely to be depressed and may even injure themselves trying to free their bonds. As the restraint practice was abandoned, the feared injuries due to falls did not turn out to be a significant issue.
"It took a regulation to stop a practice," she says. "That's what is going to have to happen with infection control. Overly aggressive isolation when the door is [always] shut is the same thing as restraints. You can't do that. You have to look at the whole person. What is going on with this person biologically? Look at their psychological, social and cognitive abilities. How can you promote health for this individual without jeopardizing others in your community?"
- Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) Infection Preventionist's Guide to Long-Term Care 2013 First edition, November 2013; ISBN: 1-933013-59-1 Washington, DC.
- Department of Health and Human Services (HHS). National Action Plan to Prevent Health-care associated Infections: Road Map to Elimination. April 2013;8:204