Healthcare Infection Prevention-Long-term care: Will an ICP be there when you are?

As many as 750,000 infections annually may occur by 2005

Our expanding population of the elderly will seek the comfort of their last days in settings where as many as 750,000 infections are projected to occur by 2005.

"It is not a pretty picture," says William Jarvis, MD, associate director for program development at the Centers for Disease Control and Prevention’s division of healthcare quality promotion, and president of the Society for Healthcare Epidemiology of America.

In 1997, for example, 1.6 million people lived in long-term care facilities. By 2005 that figure will increase to an estimated 5 million, Jarvis reports in a recent study.¹ Since 3% to 15% of such patients acquire an infection in these facilities each year, the 48,000 to 240,000 infections estimated to have occurred in 1997 will increase to an estimated 150,000 to 750,000 in 2005.

Long-term care is growing

"We need to realize this [long-term care] area is very rapidly growing, and many of us are going to end up there," Jarvis tells Healthcare Infection Prevention.

When we do, will we find a full-time infection control professional conducting surveillance to ensure our elderly bodies are not about to be invaded by multidrug-resistant bacteria from the hospital down the street? Not likely, if today’s standards for infection control do not improve in the future.

"Most of them have no infection control personnel and no hospital epidemiologist that plays a major role at all in the facility," Jarvis says. "Very few, if any, have surveillance systems. They can’t even tell you what is going on."

Indeed, uniform definitions and surveillance protocols are needed for infections acquired in long-term care facilities. That means studies are needed to determine the best numerator (e.g., number of infections, colonization, positive cultures, symptomatic or asymptomatic residents) and denominator (e.g., number of residents, number of resident days, number of residents with a specific device or device days) to use for infection rate calculations to facilitate inter- and intrafacility comparisons, he reports.

There are lab problems as well, including lack of lab facilities, failure of clinicians to order appropriate diagnostic work-ups, and inadequate reimbursement for diagnostic testing for infections. Patients in long-term care facilities often are not evaluated for infection when they are symptomatic, and antibiotics are initiated on an empiric basis.

Recipe for disaster

"What we have is the convergence of very susceptible patient populations, some [medical] devices and procedures, lots and lots of empiric antimicrobials, little diagnostic work-up of patients, and shortages of nursing personnel," Jarvis says.

Most nursing homes may have one RN a shift, with the rest licensed practical nurses or aides, he notes. "Then you have tremendous turnover in those staff," he says. "Is there anybody around to educate [new staff] about infection control? Is there anybody to monitor them about their implementation of infection control measures? Without that, you can see tremendous problems."

Given the situation, more outbreaks may occur in long-term care settings in the coming years. "The recent report of multidrug-resistant salmon-ella in a nursing home is just an example of what can happen in these facilities," says Jarvis, who has investigated all manner of health care outbreaks during his long tenure at the CDC.

Playing pingpong with infections

The aforementioned case - the first recognized outbreak of fluoroquinolone-resistant salmonella infection in the United States - was traced back to an emerging strain in the Philippines.² Similar outbreaks are likely in U.S. institutional settings as the resistant strain emerges. Transmission occurred in two nursing homes and one hospital in the Portland area.

"Patients pingpong back and forth and carry multidrug-resistant organisms from one place to the other," Jarvis says. "It just increases the problems in the future, and the likelihood that a patient will have a very serious illness with a multidrug-resistant strain that may be impossible to treat."

The irony of the situation is that the lack of infection control in any setting is typically driven by cost-saving measures. But skimping on infection control only costs the overall health system more, as infected long-term care patients are admitted and readmitted to hospitals.

"We have spent an enormous amount of time, money and research trying to improve antimicrobial use," he says. "If we put that same amount of resources in for enhancement of infection control practices, we might actually get a bigger bang for our buck."

Indeed, Jarvis emphasizes that infection control personnel can play the critical role in preventing infections and medical errors across the continuum.

"Many of the multidrug-resistant pathogens that are tormenting us now, we know can be controlled if we enhanced our infection control measures," he says. "We need to expand that throughout the health care spectrum including long-term care, or we are going to have many outbreaks to deal with and a lot of patient morbidity and mortality."

Trying to get this message out to politicians and the health care industry is "often not an easy sell," he says. But there are favorable signs in the recent national interest in patient safety, the federal task force antibiotic plan, and bioterrorism concerns. Those activities have reached the top levels of federal government, and could raise the profile of ICPs accordingly.

"To try to diminish [infection control] and think you are going to have a successful campaign against any of those problems is foolhardy," Jarvis says.

The result could be the long-awaited realization that it is cost-effective to invest infection control dollars in long-term care or anywhere across the health care spectrum.

References

1. Jarvis WR. Infection control and changing health-care delivery systems. Emerg Infect Dis 2001; 7(2). Web site: http://www.cdc.gov/ncidod/eid/vol7no2/jarvis.htm

2. Olsen SJ, DeBess EE, McGivern TE, et al. A nosocomial outbreak of fluoroquinolone-resistant salmonella infection. N Engl J Med 2001; 344:1,572-1,579. n

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