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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
"Infection Prevention and Control Practice Standards"