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Any healthcare professional who has worked in long-term care knows of the importance and also the challenges of infection control within the care community but why do skilled nursing facilities present such a dilemma in terms of preventing the spread of infection?
Well, this is where residents sleep, eat, receive medical care, participate in activities, make and spend time with friends, receive visitors and spend their holidays. More than just medical facilities, they are the resident’s community. Within this community, staff care for dozens, sometimes hundreds of patients residing in close quarters, each with unique physical challenges, emotional needs and, you guessed it, infection risks.
The difficulty of preventing the spread of infection in long-term care facilities is exacerbated by the high prevalence of bacterial colonization within the resident population. These residents carry bacteria on their skin or within their bodily fluids but without experiencing infectious processes, such as fever or cough. While the colonized individual may appear free of symptoms, they can still spread the often antibiotic-resistant bacteria to others. Furthermore, many risk factors associated with colonization, including residence in a long-term care facility, cannot be modified1.
Complicating matters, CMS guidelines for patient rights dictate that patients must be free to participate in activities, spend time with visitors and form and participate in resident groups2.
Close living quarters, bacterial colonization and patient rights all contribute to the difficulty of infection control in the long-term care setting. This is why, with over 1.5 million people living in 16,000 nursing homes in the USA, an average of 2 million infections a year are reported3. Fortunately, a multi-factorial approach to safety and prevention can assist in thwarting the spread and providing a safe and healthy environment for patients.
The first step in preventing infections is understanding how they spread. Infection transmission can occur through various routes. Contact transmission occurs when bacteria or viruses survive on an infected person’s skin or other surface and are transferred to another person as they touch the surface4. Some diseases are transmitted through droplets, existing within bodily fluids before contacting another person’s bodily fluids through sprays or splashes4. Airborne diseases are transmitted through tiny droplets that are inhaled through the air4. Lastly, vector-borne diseases are spread by insects, such as mosquitos and fleas, that bite and infect their unsuspecting victims4.
Infections will take any available route to take hold in a new host. Therefore, infection prevention practices must create security against all available passages.
An effective infection prevention protocol in long-term care must include the following:
All patient care, including that of healthy patients, must include standard precautions. These practices prevent the spread of infection even when its presence is not yet known5.
While the practice is permanently engrained in all healthcare personnel, we would be remiss if we didn’t include this all-important task in our guide. The rule of thumb is to wash:
When necessary, hands must be washed thoroughly with soap and warm water for a minimum of 15 seconds. If your hands come into contact with a bodily fluid or are visibly soiled, soap and water are the only options for cleansing. Never use hand sanitizer as an alternative in these instances. Furthermore, soap and water are the best ways to cleanse the hands, so they should be the first choice whenever available.
If soap and water are unavailable, or the hands are not soiled and have not come into contact with bodily fluids, alcohol-based hand sanitizer may be used. Hand sanitizer must be available for staff, residents and visitors throughout the facility. While not always an appropriate substitute for washing with soap and water, it is a useful tool in breaking the chain of infection, as 20 seconds of rubbing with the sanitizer can kill most germs. However, the sanitizer’s alcohol concentration must be between 60% and 95% for maximum effectiveness6. Staff should also know that alcohol is not effective in killing all types of germs, so handwashing is still best practice.
Environmental services staff are integral in breaking the chain of infection and must receive thorough infection prevention training. First, they must understand the importance of their duties and their role in preventing the spread of germs throughout the facility. Secondly, management must provide guidance on which surfaces require cleaning, how often, and to what degree. The CDC has published a thorough guide to the sanitation practices that staff can implement throughout the facility. The document itself is well worth a read in its entirety but for the sake of brevity, the following are some of the notable points you can action right now:
While environmental surfaces can harbor pathogens, they are not typically direct sources of infection transmission. However, hand contact with contaminated surfaces can transfer microorganisms, emphasizing the importance of proper hand hygiene after surface contact.
The effectiveness of cleaning and disinfecting surfaces depends on several factors, including the type and concentration of germicide used, the amount of organic matter on the surface, and the type of microorganisms present.
Cleaning is a necessary first step before disinfection, as it removes organic matter and visible soil that can interfere with the effectiveness of disinfectants. Scrubbing with detergents and water removes a significant number of microorganisms.
High-touch surfaces in patient care areas, like doorknobs and bedrails, should be cleaned and disinfected regularly. The use of EPA-registered hospital disinfectants is recommended to ensure the surfaces are properly decontaminated.
When handling spills of blood or body fluids in a skilled nursing facility, after removing visible debris, swab the area with a 1:100 dilution of bleach for routine cleaning. For larger or more concentrated spills, start with a stronger 1:10 bleach solution for the initial cleaning to ensure thorough disinfection and reduce infection risk.
PPE must always be available to facility staff during patient care and procedures.
When an infection occurs within the facility, it is crucial to provide additional PPE for all staff who will care for or come within close range of the patient, their belongings or their room. The PPE must be readily available and stocked near the patient room for ease of use. Appropriate waste bins must also be available for discarding used PPE.
If the infection can spread by contact, a gown and gloves are required for all patient interactions. Droplet precautions require that the patient wear a mask whenever they leave their room and that staff wear a mask upon entering the patient area. If the infection is an airborne pathogen, the patient must wear a mask when leaving their room, and all staff must don a fit-tested N-95 respirator before entering the patient area7.
In addition to training staff on the appropriate use of PPE, donning and doffing procedures should be posted to assist staff in recalling how to place and remove each item. You can find the CDC toolkit for performing these actions here.
While many patients would prefer a single room, most long-term care facilities cannot accommodate the request for more than a small number of their population. When considering infection control practices, management should reserve these coveted rooms for patients with infectious diseases that may be easily transmitted, such as airborne diseases or those of draining wounds, stool or uncontained secretions8. Patients infected with a pathogen that transmits via stool should be given priority for single rooms with private bathrooms when possible8.
Cohorting, grouping patients by infectious disease or colonization, should be practiced when room sharing is required8. When possible, staff should be assigned to care for cohorts of patients, reducing the number of exposures to the staff and other residents7.
Proper management of known infections is imperative in managing a disease's spread and preventing antibiotic resistance. The most common illnesses in the long-term care setting are gastrointestinal and respiratory, spreading quickly through the close living quarters9. Best practices in managing the spread of these illnesses include:
Working together, the healthcare team can prevent the spread of active infections.
An outbreak, also known as an epidemic, is the occurrence of more disease cases than expected in a specific area during a specific timeframe10. When this occurs, the entire facility must work together to implement protocols to keep residents, staff and visitors safe from further spread. Furthermore, each department must be involved in planning, ensuring adequate preparation when an epidemic arises.
Outbreak management protocols must include considerations for11:
Ensure HVAC systems are fully optimized, including proper filtration and airflow management.
Develop strategies for maintaining physical distance between residents, staff, and visitors, such as rearranging communal spaces and limiting group activities.
Regularly screen residents, visitors and staff for symptoms and potential exposures to contagious infections via questionnaires, tests or temperature checks.
Ensure that staff always have access to personal protective equipment (PPE) and understand how and when to use it. This is especially vital during an outbreak.
Develop and implement clear testing protocols including policies regarding the frequency of testing staff and residents.
Develop treatment protocols that include testing, isolation measures, medication management and care coordination of the interdisciplinary team.
Develop protocols for the safe transportation of residents outside of or within the building, taking into consideration those who are infected, are not infected and those who are particularly at risk if they are exposed to infection.
Implement rigorous environmental services protocols and enhanced training provisions in infection control principles to ensure timely and effective disinfection of high-touch areas.
Develop and implement clear communication tactics to ensure that staff, residents and families remain informed of outbreak status and infection control measures.
Coordinate with facility staff and outside organizations to ensure proper staffing levels can be maintained and shortages prevented during an outbreak. Consider cross-training some staff to defend against short staffing through illness.
Keep essential supplies including PPE, and cleaning products adequately stocked to prevent shortages during an outbreak. Have contingency plans in place for obtaining needed supplies in the event of a supply chain crisis.
While some outbreak management protocols will be more accepted and effective than others, these protocols are vitally important in managing the spread of unidentified or virulent diseases.
The key to preventing the spread of infection in long-term care is effective planning and implementation of standard precautions, careful resident placement, infection management and the management of outbreaks.
Properly communicated protocols and ensuring the availability of adequate training resources ensures that staff are ready when an infection does occur within the facility. Before your facility experiences an outbreak, take time to develop and practice communication strategies and implement education programs to help staff understand their role during an outbreak.
Some strategies for maintaining, developing and implementing thorough training and monitoring:
It’s important to advise every stakeholder invested in the well-being of residents in LTC communities that infection control is the responsibility of all parties including staff, visitors and the residents themselves. But it is not only the daily hygiene and cleaning practices that make a difference in terms of preventing the spread of diseases. Larger considerations such as DME and furniture choices must also be made with infection prevention in mind.
The Empresa FloorBed, for example, is infection control compliant in that while it is a floor-level nursing bed that lowers to the floor, only the four castor points touch the floor at any given time including when it is in its lowest position so the risk of infection is minimal without reducing the fall prevention benefits. Plus, no trailing wires further reduces the risk of accidental contact between a part of the bed and other surfaces. It’s just one of the ways that Accora makes LTC professionals’ lives just a little bit easier.
