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Infection Prevention and Control Practice Standards

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									Infection Prevention and
    Control Practice
  Standards in LTCFs
            Barbara M. Soule
  Practice Leader, Infection Prevention
          and Control Services
     Joint Commission International
   Guidelines on Prevention of Communicable Diseases in
Residential Care Homes for the Elderly – Department of Health
                   Hong Kong- 2nd Edition

• Effective prevention of communicable diseases
  in RCHEs will not only safeguard the health of
  the residents and the staff by minimizing the
  harm caused by the diseases, but will also
  reduce the chance of hospitalization of the
  residents and thus help to save community
  resources.

• It is therefore incumbent on every staff and
  resident to learn how to prevent communicable
  diseases.
              Infection Risks in RCHEs
• Residents:
   –   Unable to manage independently in the community
   –   Collective living
   –   Chronic long-term or short-term rehabilitation
   –   Susceptible to infectious diseases / infections – frailty,
       immunosuppression, multiple illnesses
• Staff:
   – Close contact with residents and their secretions /
     excretions
   – Community infections
• Visitors
   – Frequent, many, close interactions
   – Community infections
Most Common Infections in Elderly
          Homes
• Respiratory tract infections – common cold
  or pharyngitis, COPD
• Urinary tract infections- asymptomatic,
  symptomatic, catheter-associated
• Skin or subcutaneous tissue infections –
  decubitus ulcers, zoster, cellulitis, infected
  avascular extremities

  Guidelines on Prevention of Communicable Disease in RCHEs 2nd Ed: 8-11
Most Common Infections in Elderly
          Homes
• Others: gastrointestinal, acute
  conjunctivitis, AIDS, hepatitis B,
  pulmonary tuberculosis

• Multidrug Resistant Organisms
  – MRSA, Gram Negatives - common
  – VRE, Clostridium difficile – less common

  Guidelines on Prevention of Communicable Disease in RCHEs 2nd Ed: 8-11
Prevalence of infections in residential care homes
    for the elderly in Hong Kong – Chen et. al



        The overall prevalence 5.7%

   (95% confidence interval, 4.2-7.1%).
The Infection Prevention
 and Control Program
  Objectives of an Infection Prevention and
         Control Program in LTCFs
• Minimize or eliminate residential-associated and
  employee infections
• Early identification of infection risks, potential
  and actual infections
• Promotion of best health status e.g.
  immunizations, nutrition, skin, hygiene
• Risk managed environment of the facility and
  each resident
• Infection prevention and control interventions
   Long Term Care: Infection Control Program
                                    ICHE 2008;



Infrastructure

Oversight Committee
Risk Assessment
IC Plan
Infection Control
  Practitioner
    Infection prevention and control
           program functions:

       Surveillance
       Outbreak Control
       Infection and Prevention Policies and Procedures
       Isolation
       Education
       Resident Health Program
       Employee health program
       Facility Management
       Environment of Care
       Antibiotic stewardship
       Disease reporting

•
Standards for an Infection
 Prevention and Control
 (IPC) Program in LTCF
    INFRASTRUCTURE
    RISK ASSESSMENT
        IPC PLAN
Infection Prevention and Control
          Infrastructure
• Multidisciplinary committee / group to over see
  the IPC program

  – Home Manager, Nursing,
  – Visiting Medical officer
  – Infection Control Officer

  – Housekeeping services, dietary, physical therapy,
    pharmacy – desirable to optional
  – Others, depending on services
       Infection Prevention and Control
                 Infrastructure
• Formal statement of the duties and
  responsibilities of the committee, e.g.

   – Review surveillance data – health records, fever
     charts, changes in cognition, infections

   – Establish and review policies and procedures

   – Engage in problem solving and assist with outbreak
     investigation

   – Liaise with organization staff; role models and
     advocates

   – Consultation
                 Meetings
• Meet on regular basis
  – Planned and informal
  – Agenda
  – Key topics – ongoing and situation-specific
  – Emergency meetings as required
Infection Prevention and Control
          Infrastructure
• Participate in a risk assessment
  – Identify and prioritize risk issues for infections in the
    home

• Develop and approve the infection prevention
  and control plan based on the risk assessment

  – Establish measurable goals (targets)
  – Design intervention strategies
  – Determine the program evaluation process
Infection Prevention and Control
          Infrastructure
• Maintain written records
  – Agendas
  – Written minutes
  – Problem issues and resolutions
  – Other key documents
• Monitor and evaluate the effectiveness of
  the IPC program
Infection Prevention and Control
          Infrastructure
• Leadership of the Home
  – Fully engaged, educated and aware of
    infection prevention and control program
  – Remove barriers to implementing best
    practices
  – Make infection prevention visible priority in the
    home for all staff, families and visitor
  – Personal role model
  – Recognition for good performance
  The Infection Control Officer
• Formally assigned responsibility for
  implementing, monitoring and evaluating
  the IPC program
• IPC – written job description
• Familiar with care problems of residents in
  RCHEs and LTCFs
  The Infection Control Officer
• Educated about infection prevention and
  control principles and practices
• Dedicated time to perform functions
• Number of ICPs dependent on beds in
  home, complexity of patients and services
  offered
         Annual Infection Prevention and
           Control Plan for the RCHE
Step 1           Perform a Risk Assessment

Step 2                  Select Priorities

Step 3                  Determine Goals

Step 4                  Identify Objectives / Indicators
                        (Quantitative)

Step 5           Develop Strategies to Meet Goals and
                 Objectives

Step 6           Implement Strategies

Step 7           Evaluate the Plan

Step 8           Communicate Results
 Performing a Risk Assessment
           in LTCFs
• Foundation of an infection prevention and
  control program
• Structured process to establish program
  priorities and allocate resources
• Multidisciplinary approach
• Quantitative or qualitative method
Residential Care Homes - LTCFacilities
   Different infection control risks




                            Rehabilitation
    Long-Term Care
               hip                                            Co
                                                                mm
             rs      IC Risk Assessment LTCF                      un
                                                                    ica
         a de                                                          tio
                                                                          n
    Le
                            Identify Risk Targets   •Local Community
   Determine Goals                                  •Organizational
      Strategies                                    •Societal
  Evaluation Process
         •Required               Risk                 Collaborate
         •Optional
                              Assessment              •ICO, Nursing, Physician
Establish Priorities             Cycle                •Leadership - HM
                                                      •Key Staff
 •Requirements                                        •DOH, Health Authority
 •Limit Number

                   Perform            Determine Method
                 Assessment               •Quantitative
                                          •Qualitative
            •Accepted Template            •SWOT
                                          •Gap Analysis
            •Establish Timeline
   Prioritize prevention goals
          based on risks
• Goals evolve from and reflect risk
  assessment results and priorities

• Priorities and goals based on resources
  available
    A Written Infection Prevention and
        Control Plan Should Be:
•   Clear, concise, fluid; a living document
•   Include best practices
•   Reviewed periodically
•   Easy to understand
•   Disseminated to others
           Your RCHE Infection Control Plan for 2009
Priority     IC Goal                Measurable            Method(s)     Evaluation      Participating
                                    Objective                                           Staff
Reduce       Decrease number        Decrease number       Hand          Monitor rates   Nursing Staff
MRSA         of residents with      of MRSA infection     Hygiene       of MRSA         VMO and other
Infect       new MRSA               in skin wounds        Contact       infections in   physicians
             infections             acquired in the       Precautions   wounds          ICO
                                    RCHE by 25% by        Antibiotic    quarterly –
                                    June 2010                           report to
                                                          use           staff, HM,
                                                                        VMO,
                                                                        Agencies
Reduce       Reduce Sharps          Reduce from 3/qtr     Improvement   Monitor         Clinical staff
Sharps       injuries               to 1 or none per      process to    monthly –       Employee Health
Injuries      from needle sticks    quarter by Dec        reduce        report and      VMO
             among staff            2009                  sharps        report to
                                                          injuries      staff and       Inf Control
                                                                        home
                                                                        manager
Readi-       Develop and test       Triage and care for   Vaccination   Complete        ICO
ness for     plan for increase of   additional pts with   Develop       and evaluate    VMO
Out          infected patients      ILI                   triage care   plan by Oct,    Home Manager
Break of                                                  plans         2009
                                                                                        Nursing Staff
H1N1                                                      Identify
                                                          precautions                   Community
In RCHE                                                   and
                                                          treatment
           Your RCHE Infection Control Plan for 2009
Priority     IC Goal          Measurable         Method(s)      Evaluation   Participating
                              Objective                                      Staff
Decubit      Reduce number    Decrease           Improved       Review of    ICO
us           of decubitus     number of          turning        ulcer        VMO
ulcers       ulcers in        decubitus ulcers   schedule       developme    Nursing Staff
             residents        by at least 50 %   Greater        nt weekly
                              from current                                   Home Manager
                                                 attention to   Reporting
                              number by Dec.     skin care      to staff
                              2009               Maximize       weekly
                                                 mobility       Report to
                                                 Nutrition      IC
                                                                Oversight
                                                                group
                                                                monthly

URIs         Minimize number Decrease URIs       Hand           Review       ICO
             of URIs in      from current rate   hygiene        URI          Nursing Staff
             residents       by at least 25%     Respiratory    infections   Residents
                             by Dec 2009         etiquette      weekly to
                                                                staff;       Visitors
                                                 Social                      Families
                                                 activities     monthly to
                                                                ICC
                                                 visitors
IC Plan: From Risk Identification to Program
                Evaluation
Standards for an Infection
  Prevention and Control
 (IPC) Program in RCHE
   SURVEILLANCE and
    DOCUMENTATION
Surveillance
• Systematic method for collecting,
  consolidating and analyzing data
• Performed on a consistent and regular
  basis for timely data collection, analysis
  and intervention
• Based on risk assessment, priorities ,
  goals and strategies
Designing the Surveillance Plan
           for LTCF
• Focus on infections that:
  – Can be prevented
  – Occur frequently
  – Cause serious morbidity
  – Increase mortality
  – Costly to treat
  – Caused by MDROs
         Surveillance Criteria
• Clear definitions:
  – McGeer A, et. al. Infect Control Hosp
    Epidemiol 13;606-608, 1992
• Consistent application
• Determine strategy: Incidence, Prevalence,
  Total, Targeted
The Infection Prevention
 and Control Program
   INFECTION PREVENTION
        STRATEGIES
Infection Prevention Strategies
• Proactive Resident Assessments Admission
  and Ongoing
• Reduce Transmission Risks
  – Hand Hygiene
  – Personal protective equipment (PPE)
  – Isolation – Standard and transmission-based
    precautions
• Environment of Care
  – Handling contaminated supplies and equipment
  – Cleaning, disinfection and sterilization
• Best practices for patient care
  – Invasive devices, skin, nutrition
                                      Secretions and Excretions
                                          Incontinent of urine or
                                          stool
                                          Loose stools or
                                          diarrhea
                                          Wound drainage
                                          Other excretions or
                                          secretions that cannot
                                          be contained


Skin Integrity
    Non intact skin
    Open wounds
    Draining wounds
    Skin ulcers – stasis, decubitus
                 • Cognitive Abilities
                    – Intact?
                    – Impaired?
                    – Abe to cooperate?
                    – Not able to cooperate or
                      combative?
                    – Lack of understanding?




Devices
  Indwelling
  catheters
      Urinary,
      drainage
  IVs
  Tracheostomy
  Other
      Admission Assessment
• Potential for MDROS
  – Past history of infection with MDRO, e.g.
    MRSA
  – Recent stay in hospital or ICU before transfer
    or LTCF
  – Recent surgery
  – Underlying diseases
  – Antibiotic use
  – Colonized? Active infection with MDRO?
MDRO Control & LTCF
 Resources / Issues
Recommendation       Barriers          Solutions?

Administration ICPs part-time    HR/fiscal
               Multiple duties   ICP training
                                 Consultants
Education        Turnover staff Staff
Training         Staffing       retention
                 HCW skills     HCW training
                 MD not on site ATB use
MDRO             Labs off-site       How often?
Detection        Carriage multiple   What sites?
Surveillance     sites               
                 No storage          Communication
                 capacity             Resources

                                HICPAC MDROs, 2006
  MDRO Control & LTCF
   Resources/Issues
 Recommendation             Barriers        Solutions?

Infection Recognition   Atypical         Refine definitions
                        presentation     ICP support
                        ICPs part-time
                        Definitions
                        problem
Infection Control       Colonization     Establish the norm
                        common           What precautions?
                        Multiple         precautions?
                        colonizations    When to cohort?
                        Decreased        How to cohort?
                        capacity
                        Rehab mission    Decolonize?
                        Prolonged stay
                        Few benchmarks

                        HICPAC MDRO Guideline, 2006.
Assessing and Documenting Resident Risks for Infection
   Symptom or Status     Yes   No               Comment


 Fever                              See Appendix D for Fever Record for
                                    Residents
 Confusion                          See Appendix C: Checklist of signs
                                    and symptoms of communicable
                                    diseases.
 Dehydration

 Skin Integrity
 Decreased
 Catheter

 Bedridden

 Decreased nutritional
 status
 Invasive device

 Other
Infection Prevention Strategies
• Proactive Resident Assessments Admission
  and Ongoing
• Reduce Transmission Risks
  – Hand Hygiene
  – Personal protective equipment (PPE)
  – Isolation – Standard and transmission-based
    precautions
• Environment of Care
  – Handling contaminated supplies and equipment
  – Cleaning, disinfection and sterilization
• Best practices for patient care
  – Invasive devices, skin, nutrition
Chain of Infection
         Mode of Transmission

         • Direct and Indirect
           Contact: Scabies,
           Conjunctivitis
         • Droplet: Influenza
         • Airborne, TB, Chickenpox
         • Vectors: Food poisoning,
           UTI, Hepatitis A
         • Vectors: Dengue
         • BBF: Hepatitis B
         • Congenital - Syphilis
             Hand Hygiene
• One of the most effective ways to prevent
  transmission of communicable diseases in
  healthcare settings
• Reduces risk of HCW to patient, patient to
  HCW, patient to patient, HCW to HCW
Opportunity
      Hand Hygiene Methods
• Washing with soap           – After touching
  and water                     contaminated surfaces
                                 • Door knobs, bed rails,
  – Before and after caring        resident immediate
    for residents                  environment
  – After gloves are          – After changing diapers
    removed
  – After toilet, before
    eating or handling food
  – After contamination
    from secretions, e.g.
    coughing or sneezing
      Hand Hygiene Methods
• Do not share towels, use paper and
  dispose
• For personal towels, store properly and
  wash at least daily
              Hand Hygiene
• Alcohol-based
  handrub is effective if
  hands not visibly
  soiled
• Do not wash hands
  and then use alcohol
• Allow alcohol to dry
  completely
• Use adequate amount
Standard and Transmission Based
      PPE and Precautions




                Balance between social needs
                and infection prevention and
                control requirements
Infection Prevention Strategies
• Proactive Resident Assessments Admission
  and Ongoing
• Reduce Transmission Risks
  – Hand Hygiene
  – Personal protective equipment (PPE)
  – Isolation – Standard and transmission-based
    precautions
• Environment of Care
  – Handling contaminated supplies and equipment
  – Cleaning, disinfection and sterilization
• Best practices for patient care
  – Invasive devices, skin, nutrition
 Maintaining a safe environment in
             the LTCF
• Therapy equipment
  – Canes, Wheelchairs, Lifts, Transfer devices
• Aquatic : pools, tubs
  – Discard water, clean, attend to drains,
    disinfectant (chlorine, other),
• Patient room, procedure and counseling
  rooms
General cleaning and disinfection of all patient
   care equipment and patient care areas

  • Specific guidelines for cleaning surfaces
    and equipment
  • Written procedures in place
  • All staff educated
  • Monitoring process and effectiveness
  • Select effective disinfectant – least toxic
    – Appropriate cleaning procedures
        Cleaning Equipment
• Proper type and level of disinfectant in
  pools and tanks
• Exclude patients who cannot contain feces
  or wound drainage or use special
• Agitator jets disinfected with solution and
  circulated
         Cleaning Equipment
• Reuse of equipment must follow strict
  cleaning and disinfection procedures
  – e.g., last patient of the day
• Separate clean from dirty equipment
• Clean versus sterile procedures
  – E. g., clean intermittent catheterization of
    inpatients or teaching for home at discharge
Infection Prevention Strategies
• Proactive Resident Assessments Admission
  and Ongoing
• Reduce Transmission Risks
  – Hand Hygiene
  – Personal protective equipment (PPE)
  – Isolation – Standard and transmission-based
    precautions
• Environment of Care
  – Handling contaminated supplies and equipment
  – Cleaning, disinfection and sterilization
• Best practices for patient care
  – Skin, nutrition, invasive devices,
   Employee Health Program
• Baseline assessment on hire
  – Immunization status
  – Past and current diseases
• Current Immunizations: TST, HBV,
  Influenza, other
• Education on HH, BBP, PPE, exposure
  protocols, signs/sx disease, work
  restrictions, reporting
        Education and Policies /
             Procedures
• All staff at hire and periodically thereafter
• Timely and relevant
• Document education
• Evaluate learning
• Basic infection prevention measures,
  standards, responsibilities
• Develop, implement and monitor policies
       Antibiotic Stewardship
• Policies and oversight for judicious use of
  antibiotics
• Monitor antibiotic susceptibility culture
  results and utilization and appropriateness
  of antibiotics
• Identify epidemiologically significant
  organisms ( MRSA, Gram Negatives)
• Communicate to ICC
Summary of Practice Standards for
             LTCF
• Assess IC Risks for Program and Residents
• Have a plan, implement it and evaluate it
• Use evidence-based strategies to reduce or
  eliminate risks
  – Clinical
  – Environmental
• Educate staff, family and visitors
• Measure and document processes and
  outcomes
  – Hand hygiene
  – Compliance with isolation and PPE
  – Infections
                References
• Smith PW, et al. SHEA/APIC Guidelines:
  Infection prevention and control in the long term
  care facility. Am J Infect Control 2008;36;504-35.

• Guidelines on Prevention of Communicable
  Diseases in Residential Care Homes for the
  Elderly (RCHEs) Department of Health, Hong
  Kong, 2nd Ed

• Mary Claire Roghman, MD and Suzanne
  Bradley, MD

								
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