Long-term care facilities (LTCFs) may be defined as institutions that provide health
care to people who are unable to manage independently in the community.
1
This care may be chronic care management or short-term rehabilitative services. The
term nursing home is defined as a facility licensed with an organized professional
staff and inpatient beds that provides continuous nursing and other services to patients
who are not in the acute phase of an illness. There is considerable overlap between
the 2 terms.
More than 1.5 million residents reside in United States (US) nursing homes. In recent
years, the acuity of illness of nursing home residents has increased. LTCF residents
have a risk of developing health care-associated infection (HAI) that approaches that
seen in acute care hospital patients. A great deal of information has been published
concerning infections in the LTCF, and infection control programs are nearly universal
in that setting. This position paper reviews the literature on infections and infection
control programs in the LTCF.
Recommendations are developed for long-term care (LTC) infection control programs
based on interpretation of currently available evidence. The recommendations cover
the structure and function of the infection control program, including surveillance,
isolation precautions, outbreak control, resident care, and employee health. Infection
control resources are also presented.
Hospital infection control programs are well established in the US. Virtually every
hospital has an infection control professional (ICP), and many larger hospitals have
a consulting hospital epidemiologist. The Study on the Efficacy of Nosocomial Infection
Control (SENIC) documented the effectiveness of a hospital infection control program
that applies standard surveillance and control measures.
2
The major elements leading to a HAI are the infectious agent, a susceptible host,
and a means of transmission. These elements are present in LTCFs as well as in hospitals.
It is not surprising, therefore, that almost as many HAIs occur annually in LTCFs
as in hospitals in the US.
3
The last 2 decades have seen increased recognition of the problem of infections in
LTCFs, with subsequent widespread development of LTCF infection control programs and
definition of the role of the ICP in LTCFs. An increasingly robust literature is devoted
to LTC infection control issues such as the descriptive epidemiology of LTCF infections,
the microbiology of LTCF infections, outbreaks, control measures, and isolation. Nevertheless,
there is as yet no SENIC-equivalent study documenting the efficacy of infection control
in LTCFs, and few controlled studies have analyzed the efficacy or cost-effectiveness
of the specific control measures in that setting.
Although hospitals and LTCFs both have closed populations of patients requiring nursing
care, they are quite different. They differ with regard to payment systems, patient
acuity, availability of laboratory and x-ray, and nurse-to-patient ratios. More fundamentally,
the focus is different. The acute care facility focus is on providing intensive care
to a patient who is generally expected to recover or improve, and high technology
is integral to the process. In LTCFs, the patient population may be very heterogeneous.
Most LTCFs carry out plans of care that have already been established in acute care
or evaluate chronic conditions. The LTCF is functionally the home for the resident,
who is usually elderly and in declining health and will often stay for years, hence
comfort, dignity, and rights are paramount. It is a low-technology setting. Residents
are often transferred between the acute care and the LTC setting, adding an additional
dynamic to transmission and acquisition of HAIs.
Application of hospital infection control guidelines to the LTCF is often unrealistic
in view of the differences noted above and the different infection control resources.
Standards and guidelines specific to the LTCF setting are now commonly found. The
problem of developing guidelines applicable to all LTCFs is compounded by the varying
levels of nursing intensity (eg, skilled nursing facility vs assisted living), LTCF
size, and access to physician input and diagnostic testing.
This position paper provides basic infection control recommendations that could be
widely applied to LTCFs with the expectation of minimizing HAIs in LTC. The efficacy
of these measures in the LTCF, in most cases, is not proven by prospective controlled
studies but is based on infection control logic, adaptation of hospital experience,
LTCF surveys, Centers for Disease Control and Prevention (CDC) and other guidelines
containing specific recommendations for LTCFs, and field experience. Every effort
will be made to address the unique concerns of LTCFs. Because facilities differ, the
infection risk factors specific to the resident population, the nature of the facility,
and the resources available should dictate the scope and focus of the infection control
program.
In a number of instances, specific hospital-oriented guidelines have been published
and are referenced (eg, guidelines for prevention of intravascular (IV) device-associated
infection). These guidelines are relevant, at least in part, to the LTC setting but
may be adapted depending on facility size, resources, resident acuity, local regulations,
local infection control issues, etc. Reworking those sources to a form applicable
to all LTCFs is beyond the scope of this guideline.
Any discussion of infection control issues must be made in the context of the LTCF
as a community. The LTCF is a home for residents, a home in which they usually reside
for months or years; comfort and infection control principles must both be addressed.
Background
Demography and definitions
The US population aged 65 to 85 years is increasing rapidly, and the population aged
85 years and older is expected to double by 2030.
4
One of every 4 persons who reach the age of 65 can be expected to spend part of his
or her life in a nursing home; more people occupy nursing home beds than acute care
hospital beds in the US.
5
Approximately 1.5 million persons in the US reside in a nursing home; there are 15,000
nursing homes in this country.
6
Ninety percent of nursing home residents are over 65 years of age, and the mean age
of residents is over 80 years.
A LTCF is a residential institution for providing nursing care and related services
to residents. It may be attached to a hospital (swing-bed) or free standing; the latter
is often called a nursing home. A resident is a person living in the LTCF and receiving
care, analogous to the patient in a hospital.
Scope of position paper
This position paper addresses all levels of care in the LTCF. The focus is specifically
the LTCF, also known as the nursing home, caring for elderly or chronically ill residents.
These recommendations generally also should apply to special extended care situations
(such as institutions for the mentally retarded, psychiatric hospitals, pediatric
LTCFs, and rehabilitation hospitals). However, other extended care facilities may
have different populations (eg, the residents of institutions for the mentally retarded
are much younger than nursing home residents), different disease risks (eg, hepatitis
B in psychiatric hospitals), or different levels of acuity and technology (eg, higher
acuity in long-term acute care facilities or LTACs). Thus, the recommendations may
need to be adapted for these special extended care situations.
Changes from prior Guideline
This position paper is similar to the 1997 Society for Healthcare Epidemiology of
America (SHEA)/Association for Professionals in Infection Control and Epidemiology
(APIC) guideline,
7
although the present version reflects an updating of research and experience in the
field. Several important areas of discussion are new or changed.
Infections in the long-term care facility
Epidemiology
In US LTCFs, 1.6 million to 3.8 million infections occur each year.
8
In addition to infections that are largely endemic, such as urinary tract infections
(UTIs) and lower respiratory tract infections (LRTIs), outbreaks of respiratory and
gastrointestinal (GI) infections are also common.
9
The overall infection rate in LTCFs for endemic infections ranges from 1.8 to 13.5
infections per 1000 resident-care days.
8
For epidemics, good estimates are difficult to ascertain, but the literature suggests
that several thousand outbreaks may occur in US LTCFs each year.8, 9 The wide ranges
of infections and resulting mortality and costs illustrate the challenge in understanding
the epidemiology of infections and their impact in LTCFs. There are currently little
data and no national surveillance systems for LTCF infections; the estimates have
been calculated based on research studies and outbreak reports from the medical literature.
As a part of aging, the elderly have diminished immune response including both phenotypic
and functional changes in T cells.
10
However, these changes are of limited clinical significance in healthy elderly. Consequently,
immune dysfunction in elderly residents of LTCFs is primarily driven by the multiple
factors that result in secondary immune dysfunction such as malnutrition, presence
of multiple chronic diseases, and polypharmacy, especially with medications that diminish
host defenses (eg, immunosuppressants).11, 12 In addition, LTCF residents often have
cognitive deficits that may complicate resident compliance with basic sanitary practices
(such as handwashing and personal hygiene) or functional impairments such as fecal
and urinary incontinence, immobility, and diminished cough reflex. The elderly nursing
home resident is known to have a blunted febrile response to infections.
13
This parallels other age-related immunologic abnormalities. A notable fever in this
population often signals a treatable infection, such as UTI or aspiration pneumonia.
While the use of urinary catheters in LTCF residents has decreased in recent years,
utilization remains around 5%. In LTC residents, the use of invasive devices (eg,
central venous catheters, mechanical ventilators, enteral feeding tubes) increases
the likelihood of a device-associated infection. Of the over 15,000 LTCFs in the US
in 2004, 42% provided infusion therapy, 22% had residents with peripherally-inserted
central lines, and 46% provided parenteral nutrition.
14
Another challenge for preventing infections in LTCFs is the increasing acuity of residents,
especially with the rapidly growing subpopulation of postacute residents. Postacute
residents are hospitalized patients who are discharged to LTCFs to receive skilled
nursing care or physical/occupational therapy. In the past, these patients, often
frail, would have remained hospitalized, but, with increasing efforts to control hospital
costs, these patients are now discharged to LTCFs. In addition to higher device utilization,
these residents are more likely to receive antimicrobial therapy than long-stay LTCF
residents.
15
Much remains to be learned about resident and LTCF factors correlated with HAIs. There
is evidence that institutional factors such as nurse turnover, staffing levels, prevalence
of Medicare recipients, rates of hospital transfer for infection, intensity of medical
services, and family visitation rates are associated with incidence of HAI in the
LTC setting.
16
The rate of deaths in LTCF residents with infections ranges from 0.04 to 0.71 per
1000 resident-days, with pneumonia being the leading cause of death.
8
Infections are a leading reason for hospital transfer to LTCF residents, and the resulting
hospital costs range from $673 million to $2 billion each year.
8
LTCFs and acute care facilities differ in another key aspect: LTCFs are residential.
As residences, LTCFs are required to provide socialization of residents through group
activities. While these activities are important for promoting good physical and mental
health, they may also increase communicable infectious disease exposure and transmission.
Occupational and physical therapy activities, while vital toward restoring or maintaining
physical and mental function, may increase risk for person-to-person transmission
or exposure to contaminated environmental surfaces (eg, physical or occupational therapy
equipment).
Specific nosocomial infections in the long-term care facility
Urinary tract infections
In most surveys, the leading infection in LTCFs is UTI,
17
although with restrictive clinical definitions, symptomatic urinary infection is less
frequent than respiratory infection.
18
Bacteriuria is very common in residents of these facilities but, by itself, is not
associated with adverse outcomes and does not affect survival.19, 20 Bacteriuria and
UTI are associated with increased functional impairment, particularly incontinence
of urine or feces.21, 22
The symptoms of UTI are dysuria and frequency (cystitis) or fever and flank pain (pyelonephritis).
The elderly may present with atypical or nonlocalizing symptoms. Chronic genitourinary
symptoms are also common but are not attributable to bacteriuria.20, 21 Because the
prevalence of bacteriuria is high, a positive urine culture, with or without pyuria,
is not sufficient to diagnose urinary infection.
20
Clinical findings for diagnosis of UTI in the noncatheterized resident must include
some localization to the genitourinary tract.
23
The diagnosis also requires a positive quantitative urine culture. This is obtained
by the clean-catch voided technique, by in and out catheterization, or by aspiration
through a catheter system sampling port. A negative test for pyuria or a negative
urine culture obtained prior to initiation of antimicrobial therapy excludes urinary
infection.
The prevalence of indwelling urethral catheters in the LTCF is 7% to 10%.24, 25, 26
Catheterization predisposes to clinical UTI, and the catheterized urinary tract is
the most common source of bacteremia in LTCFs.17, 19 Residents with long-term catheters
often present with fever alone. Residents with indwelling urinary catheters in the
LTCF are uniformly colonized with bacteria, largely attributable to biofilm on the
catheter.
27
These organisms are often more resistant to oral antibiotics than bacteria isolated
from elderly persons in the community.28, 29 Catheter-related bacteriuria is dynamic,
and antimicrobial treatment only leads to increased antimicrobial resistance.
30
Thus, it is inappropriate to screen asymptomatic catheterized residents for bacteriuria
or to treat asymptomatic bacteriuria.
20
Specimens collected through the catheter present for more than a few days reflect
biofilm microbiology. For residents with chronic indwelling catheters and symptomatic
infection, changing the catheter immediately prior to instituting antimicrobial therapy
allows collection of a bladder specimen, which is a more accurate reflection of infecting
organisms.
31
Catheter replacement immediately prior to therapy is also associated with more rapid
defervescence and lower risk of early symptomatic relapse posttherapy.
31
Guidelines for prevention of catheter-associated UTIs in hospitalized patients
32
are generally applicable to catheterized residents in LTCFs. Recommended measures
include limiting use of catheters, insertion of catheters aseptically by trained personnel,
use of as small diameter a catheter as possible, handwashing before and after catheter
manipulation, maintenance of a closed catheter system, avoiding irrigation unless
the catheter is obstructed, keeping the collecting bag below the bladder, and maintaining
good hydration in residents. Urinary catheters coated with antimicrobial materials
have the potential to decrease UTIs but have not been studied in the LTCF setting.
For some residents with impaired voiding, intermittent catheterization is an option,
and clean technique is as safe as sterile technique.
33
External catheters are also a risk factor for UTIs in male residents
34
but are significantly more comfortable and associated with fewer adverse effects,
including symptomatic urinary infection, than an indwelling catheter.
35
Local external care is required. The CDC guideline
32
briefly discusses care of condom catheters and suprapubic catheters, but no guideline
for leg bags is available. Leg bags allow for improved ambulation of residents but
probably increase the risk of UTI because opening of the system and reflux of urine
from the bag to the bladder occur more frequently than with a standard closed system.
Suggestions for care of leg bags include using aseptic technique when disconnecting
and reconnecting, disinfecting connections with alcohol, changing bags at regular
intervals, rinsing with diluted vinegar, and drying between uses.
36
A 1:3 dilution of white vinegar has been recommended for leg bag disinfection.
37
Respiratory tract infections
Because of the impaired immunity of elderly persons, viral upper respiratory infections
(URIs) that generally are mild in other populations may cause significant disease
in the institutionalized elderly patient.38, 39 Examples include influenza, respiratory
syncytial virus (RSV), parainfluenza, coronavirus, rhinoviruses, adenoviruses, and
recently discovered human metapneumovirus.
40
Pneumonia
Pneumonia or lower respiratory tract infection (LRTI) is the second most common cause
of infection among nursing home residents, with an incidence ranging from 0.3 to 2.5
episodes per 1000 resident care-days and is the leading cause of death from infections
in this setting. Elderly LTCF residents are predisposed to pneumonia by virtue of
decreased clearance of bacteria from the airways and altered throat flora, poor functional
status, presence of feeding tubes, swallowing difficulties, and aspiration as well
as inadequate oral care.41, 42, 43 Underlying diseases, such as chronic obstructive
pulmonary disease and heart disease, further increase the risk of pneumonia in this
population.
44
The clinical presentation of pneumonia in the elderly often is atypical. While there
is a paucity of typical respiratory symptoms, recent studies have shown that fever
is present in 70%, new or increased cough in 61%, altered mental status in 38%, and
increased respiratory rate above 30 per minute in 23% of residents with pneumonia.
45
While acquiring a diagnostic sputum can be difficult, obtaining a chest radiograph
is now more feasible than in the past. In general it is recommended that a pulse oximetry,
chest radiograph, complete blood count with differential, and blood urea nitrogen
should be obtained in residents with suspected pneumonia.
46
Streptococcus pneumoniae appears to be the most common etiologic agent accounting
for about 13% of all cases,47, 48 followed by Hemophilus influenzae (6.5%), Staphylococcus
aureus (6.5%), Moraxella catarrhalis (4.5%), and aerobic gram-negative bacteria (13%).
44
Legionella pneumoniae also is a concern in the LTCF. Colonization with methicillin-resistant
S aureus (MRSA) and antibiotic-resistant, gram-negative bacteria further complicate
diagnosis and management of pneumonia in LTCF residents.49, 50
The mortality rate for LTCF-acquired pneumonia is significantly higher than for community-acquired
pneumonia in the elderly population.
51
Preinfection functional status, dementia, increased rate of respirations and pulse,
and a change in mental status are considered to be poor prognostic factors. Several
indices predictive of mortality have been developed and may be useful in managing
residents with pneumonia.45, 52, 53
The CDC guideline for prevention of pneumonia
54
is oriented toward acute care hospitals but covers a number of points relevant to
the LTCF, including respiratory therapy equipment, suctioning techniques, tracheostomy
care, prevention of aspiration with enteral feedings, and immunizations. Examples
of relevant recommendations for the LTCF include hand hygiene after contact with respiratory
secretions, wearing gloves for suctioning, elevating the head of the bed 30 to 45
degrees during tube feeding and for at least 1 hour after to decrease aspiration,
and vaccination of high-risk residents with pneumococcal vaccine.
54
The evidence for the efficacy of pneumococcal vaccine in high-risk populations, including
the elderly population, is debated.55, 56 However, the vaccine is safe, relatively
inexpensive, and recommended for routine use in individuals over the age of 65 years.56,
57 Pneumococcal vaccination rates for a facility are now publicly reported at the
Centers for Medicare and Medicaid Services (CMS).
58
Influenza
Influenza is an acute respiratory disease signaled by the abrupt onset of fever, chills,
myalgias, and headache along with sore throat and cough, although elderly LTCF residents
may not have this typical presentation. The incubation period for influenza is approximately
1 to 2 days.
59
It is a major threat to LTCF residents, who are among the high-risk groups deserving
preventive measures.
60
Influenza is very contagious, and outbreaks in LTCFs are common and often severe.
Clinical attack rates range from 25% to 70%, and case fatality rates average over
10%.61, 62, 63, 64
A killed virus vaccine is available but must be given annually. Influenza vaccine
in the elderly is approximately 40% effective at preventing hospitalization for pneumonia
and approximately 50% effective at preventing hospital deaths from pneumonia.
65
Although concern has been expressed regarding the efficacy of the influenza vaccine
in institutionalized elderly patients, most authors feel that the influenza vaccine
is effective and indicated for all residents and caregivers.63, 64, 65, 66, 67, 68
Recent surveys have shown an increased rate of influenza vaccination among LTCF residents,
although significant variability exists.69, 70 Influenza vaccination rates for a facility
are now publicly reported at the Centers for Medicare and Medicaid (CMS) Web site
http://www.medicare.gov/NHCompare/home.asp. Staff immunization rates remain less impressive,
with average immunization rates between 40% and 50% at best.
While viral cultures from nasopharynx remain the gold standard for diagnosis of influenza,
several rapid diagnostic methods (rapid antigen tests) such as immunofluorescence
or enzyme immunoassay have been developed. These tests detect both influenza A and
B viral antigens from respiratory secretions. Amantadine-resistant influenza has caused
LTCF outbreaks and hence amantadine is not recommended for influenza prophylaxis.
71
Zanamivir and oseltamivir are effective against both influenza A and B and have been
approved for prophylaxis and treatment of influenza A and B. Oseltamivir is administered
orally and is excreted in the urine requiring dose adjustments for renal impairment.
Zanamivir is given by oral inhalation, which is a problem in a noncooperative LTCF
resident.
Rapid identification of cases in order to promptly initiate treatment and isolate
them to prevent transmission remains the key to controlling influenza outbreaks. Other
measures recommended during an outbreak of influenza include restricting admissions
or visitors and cohorting of residents with influenza.60, 72, 73 Infected staff should
not work.
Tuberculosis
Tuberculosis (TB) also has caused extensive outbreaks in LTCFs, generally traced to
a single ambulatory resident. Large numbers of staff and residents may be involved,
with a potential to spread in the community.74, 75, 76 Price and Rutala
77
found 8.1% of new employees and 6.4% of new residents to be positive by the purified
protein derivative (PPD) of tuberculin method in their North Carolina survey, with
significant 5-year skin test conversion rates in both groups.
The diagnosis of TB in the LTCF is problematic. Clinical signs (fever, cough, weight
loss) are nonspecific. Chest radiographs, when obtained, often show characteristic
pulmonary infiltrates (eg, cavities in the upper lung fields). Infection with TB usually
causes a positive tuberculin skin test (TST), although occasional false positives
and false negatives are seen. The specificity of the TST may be improved by an in
vitro blood test of interferon release in response to TB peptides, such as the quantiferon
test. The most specific diagnostic test is a sputum culture for TB, but a good specimen
may be difficult to obtain. Recent advances in microbiology have facilitated the diagnosis
of TB greatly. Diagnostics such as radiometric systems, polymerase chain reaction
(PCR), as well as specific DNA probes help shorten the time for diagnosis of TB, although
susceptibility testing requires several weeks.
Guidelines discussing standards for control of TB in institutions are available.78,
79, 80, 81 There appears to be a consensus that TST of residents and personnel in
the LTCF should be undertaken on a regular basis, although many LTCFs have inadequate
TB screening programs.
82
The cost-effectiveness of using a 2-step TST to survey for the booster effect is not
demonstrable for all populations, but the 2-step skin test is recommended by the CDC
for initial screening of employees and residents. For LTCF residents without any known
contact with a case of known TB or other significant risk factors such as human immunodeficiency
virus (HIV) or immunosuppression, induration of 10 mm or greater to PPD injection
is considered positive. Induration of 5 mm or greater is considered positive in any
individual with recent contact with a known case of TB or other significant risk factors
such as immunosuppression or changes on chest x-ray consistent with old TB.
83
There was a resurgence of TB in the US in the mid-1980s; multidrug-resistant cases
of TB have been seen, and nosocomial spread within health care facilities is a concern.
84
In response to this, guidelines have been promulgated by the CDC that address surveillance
(identification and reporting of all TB cases in the facility including residents
and staff); containment (recommended treatment under directly observed therapy and
appropriate respiratory isolation and ventilation control measures); assessment (monitoring
of surveillance and containment activities); and ongoing education of residents, families,
and staff.
85
Since most LTCFs do not have a negative-pressure room, residents with suspected active
TB should be transferred to an appropriate acute care facility for evaluation. There
should be a referral agreement with that facility.
Skin and soft-tissue infections, infestations
Pressure ulcers (also termed decubitus ulcers) occur in up to 20% of residents in
LTCFs and are associated with increased mortality.86, 87, 88 Infected pressure ulcers
often are deep soft-tissue infections and may have underlying osteomyelitis; secondary
bacteremic infections have a 50% mortality rate.
88
They require costly and aggressive medical and surgical therapy. Once infected, pressure
ulcer management requires a multidisciplinary approach with involvement of nursing,
geriatrics and infectious disease specialists, surgery, and physical rehabilitation.
Medical factors predisposing to pressure ulcers have been delineated
86
and include immobility, pressure, friction, shear, moisture, incontinence, steroids,
malnutrition, and infection. Reduced nursing time can also increase the risk of developing
pressure ulcers. Several of these factors may be partially preventable (such as malnutrition
and fecal incontinence). Prevention of pressure ulcers involves developing a plan
for turning, positioning, eliminating focal pressure, reducing shearing forces, and
keeping skin dry. Attention to nutrition, using disposable briefs and identifying
residents at a high risk using prediction tools can also prevent new pressure ulcers.
The goals are to treat infection, promote wound healing, and prevent future ulcers.
Many physical and chemical products are available for the purpose of skin protection,
debridement, and packing, although controlled studies are lacking in the area of pressure
ulcer prevention and healing.
89
A variety of products may be used to relieve or distribute pressure (such as special
mattresses, kinetic beds, or foam protectors) or to protect the skin (such as films
for minimally draining stage II ulcers, hydrocolloids and foams for moderately draining
wounds, alginates for heavily draining wounds). Negative-pressure wound therapy (vacuum
dressings) using gentle suction to provide optimal moist environment is increasingly
being used in treatment of complex pressure ulcers.
90
Nursing measures such as regular turning are essential as well. A pressure ulcer flow
sheet is a useful tool in detecting and monitoring pressure ulcers and in recording
information such as ulcer location, depth, size, stage, and signs of inflammation
as well as in timing of care measures. Infection control measures include diligent
hand hygiene and glove usage.
Because all pressure ulcers, like the skin, are colonized with bacteria, antibiotic
therapy is not appropriate for a positive surface swab culture without signs and symptoms
of infection. Nonintact skin is more likely to be colonized with pathogens. True infection
of a pressure ulcer (cellulitis, osteomyelitis, sepsis) is a serious condition, generally
requiring broad-spectrum parenteral antibiotics and surgical debridement in an acute
care facility.
Cellulitis (infection of the skin and soft tissues) can occur either at the site of
a previous skin break (pressure ulcer) or spontaneously. Skin infections generally
are caused by group A streptococci or S aureus. Outbreaks of group A streptococcal
infections have been described, presenting as cellulitis, pharyngitis, pneumonia,
or septicemia.91, 92, 93
Scabies is a contagious skin infection caused by a mite. Lesions usually are very
pruritic, burrow-like, and associated with erythema and excoriations, usually in interdigital
spaces of the fingers, palms and wrists, axilla, waist, buttocks, and the perineal
area. However, these typical findings may be absent in debilitated residents, leading
to large, prolonged outbreaks in LTCFs.94, 95, 96 Diagnosis in an individual with
a rash requires a high index of suspicion in order to recognize the need for diagnostic
skin scrapings. The presence of a proven case should prompt a thorough search for
secondary cases. A single treatment with permethrin or lindane usually is effective,
but repeated treatment or treatment of all LTCF residents, personnel, and families
occasionally is necessary.97, 98 Ivermectin, an oral antihelminthic agent, is an effective,
safe, and inexpensive option for treatment of scabies. However, it has not been approved
by the FDA for this indication. Therapy of rashes without confirming the diagnosis
of scabies unnecessarily exposes residents to the toxic effects of the topical agents.
Because scabies can be transmitted by linen and clothing, the environment should be
cleaned thoroughly. This includes cleaning inanimate surfaces, hot-cycle washing of
washable items (clothing, sheets, towels, etc), and vacuuming the carpet.
Other infections
Viral gastroenteritis (caused by rotavirus, enteroviruses, or noroviruses),99, 100
bacterial gastroenteritis (caused by Clostridium difficile, Bacillus cereus, Escherichia
coli, Camplylobacter spp, C perfringens, or Salmonella spp), and parasites (such as
Giardia lambia) are well-known causes of diarrhea outbreaks in LTCFs.101, 102, 103,
104, 105, 106
The elderly are at increased risk of infectious gastroenteritis due to age-related
decrease in gastric acid. In a population with a high prevalence of incontinence,
the risk of cross infection is substantial. Person-to-person spread, particularly
due to shared bathroom, dining, and rehabilitation facilities, plays a role in viral
gastroenteritis and in Shigella spp and C difficile diarrhea.
107
Foodborne disease outbreaks also are very common in this setting,
108
most often caused by Salmonella spp or S aureus. E coli O157:H7 and Giardia also may
cause foodborne outbreaks, underscoring the importance of proper food preparation
and storage.
Bacteremia109, 110, 111 in the LTCF, although rarely detected, may be primary or secondary
to an infection at another site (pneumonia, UTI). The most common source of secondary
bacteremia is the urinary tract, with E coli being the culprit in over 50% of cases.109,
111 As the acuity of illness in LTCF residents has risen, the prevalence of IV devices
and related bacteremic complications appears to have increased. The CDC guideline
for prevention of IV infections is a useful resource and generally applicable to the
LTCF.
112
Relevant points include aseptic insertion of the IV cannula, daily inspection of the
IV for complications such as phlebitis, and quality control of IV fluids and administration
sets.
Conjunctivitis in the adult presents as ocular pain, redness, and discharge. In the
LTCF, cases may be sporadic or outbreak-associated.
113
Many cases are nonspecific or of viral origin; S aureus appears to be the most frequent
bacterial isolate.
114
Epidemic conjunctivitis may spread rapidly through the LTCF. Transmission may occur
by contaminated eye drops or hand cross contamination. Gloves should be worn for contact
with eyes or ocular secretions, with hand hygiene performed immediately after removing
gloves.
Many additional infections have been encountered in the LTCF, including herpes zoster,
herpes simplex, endocarditis, viral hepatitis, septic arthritis, and abdominal infections.
There has been a resurgence of “pediatric” infections in the LTCF (eg, pertussis,
RSV, and H influenzae respiratory tract infections), reflecting the decline of the
host's immunologic memory with aging.
Epidemic infections in the LTCF
Most LTCF HAIs are sporadic. Many are caused by colonizing organisms with relatively
low virulence. Tissue invasion may be facilitated by the presence of a urinary catheter
or chronic wound or following an aspiration event. Ongoing surveillance (see Surveillance
section below) is required to detect epidemic clustering of transmissible, virulent
infections. Outbreaks must be anticipated. Ideally, infection control surveillance
and practices should be the responsibility of frontline staff as well as infection
control staff.
An outbreak or transmission within the facility may occur explosively with many clinical
cases appearing within a few days or may, for example, involve an unusual clustering
of MRSA clinical isolates on a single nursing unit over several months. On the other
hand, a case of MRSA infection may follow a prolonged period of asymptomatic nasal
colonization after an aspiration event or development of a necrotic wound.
115
Outbreaks in LTCFs accounted for a substantial proportion (15%) of reported epidemics
116
(Table 1
). Clustering of URIs, diarrhea, skin and soft tissue infection, conjunctivitis, and
antibiotic-resistant bacteriuria have been noted.
9
Major outbreaks of infection have also been ascribed to E coli,
117
group A streptococci,92, 118
C difficile
104, 119 respiratory viruses,
38
Salmonella spp,
120
Chlamydia pneumoniae,121, 122
Legionella spp,
123
and gastrointestinal viruses.
124
Nursing homes accounted for 2% of all foodborne disease outbreaks reported to the
CDC (1975-1987) and 19% of outbreak-associated deaths.
125
Transmissible gastrointestinal pathogens may be introduced to the facility by contaminated
food or water or infected individuals. High rates of fecal incontinence, as well as
gastric hypochlorhydria, make the nursing home ideal for secondary fecal-oral transmission.
126
Other epidemics include scabies, hepatitis B,
127
group A streptococcal infections, viral conjunctivitis, and many other infections.
Table 1
Common long-term care facility epidemics
Respiratory:
Influenza
Tuberculosis
S pneumoniae
Chlamydia pneumoniae
Legionella spp
Other respiratory viruses (Parainfluenza, RSV)
Gastrointestinal: (may be foodborne)
Viral gastroenteritis (Norovirus, etc)
Clostridium difficile
Salmonellosis
E coli 0157:H7 colitis
Other infections:
Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Enterococcus (VRE)
Group A Streptococcus
Scabies
Conjunctivitis
These outbreaks underscore the vulnerability of the elderly to infection, as well
as the role of cross infection in residents with urinary catheters and open wounds
or in those with incontinence who require serial contact care by staff.
120
In addition, mobile residents with poor hygiene may interact directly.
Antibiotic-resistant bacteria
Multidrug resistant organisms (MDROs) such as MRSA, vancomycin-resistant enterococci
(VRE), drug-resistant S pneumoniae, and multidrug-resistant gram-negative bacteria
(eg, Pseudomonas aeruginosa, Acinetobacter spp and extended-spectrum β-lactamase (ESBL)-producing
enterobacteriaceae) are increasingly important causes of colonization and infection
in LTCFs.128, 129, 130, 131, 132, 133, 134, 135, 136, 137 In this setting, infection
with MDROs has been associated with increased morbidity, mortality, and cost,138,
139 although the attributable morbidity, mortality, and cost of MDROs has not yet
been fully defined. Indeed, LTCF residence has been frequently identified as a risk
factor for antibiotic-resistant infection in hospitalized patients.140, 141
Elderly and disabled residents are at increased risk for colonization with resistant
organisms, and colonization may persist for long periods of time (ie, months to years).133,
142, 143, 144, 145, 146 Within the LTCF, length of stay in the facility and accommodation
in rooms with multiple beds have been identified as risk factors for transmission
of MRSA.
147
Both infected and colonized residents may serve as sources for the spread of MDROs
in the LTCF.135, 148 When MRSA becomes endemic within a facility, elimination is highly
unlikely.
148
LTCFs can expect infections with MDROs to be a continuing problem. Strategies for
curbing the emergence and spread of antimicrobial resistance in LTCFs are discussed
below in “Antibiotic Stewardship” and “Isolation and Precautions” sections.
The infection control program
Evolution of programs
The 1980s saw a dramatic increase in LTCF infection control activities, stimulated
by federal and state regulations. Several studies provide insight into the extent
of program development. A 1981 survey of Utah LTCFs
113
noted that all facilities had regular infection control meetings, but none performed
systematic surveillance for infections or conducted regular infection control training.
All LTCFs had policies regarding the maintenance and care of urinary catheters, although
the policies were not uniform. Price et al
149
surveyed 12 North Carolina LTCFs in 1985 and found that, although all 12 had a designated
ICP, none of the ICPs had received special training in this area. Also noted were
deficiencies in isolation facilities, particularly an insufficient number of sinks
and recirculated, inadequately filtered air.
In a 1985 survey of Minnesota LTCFs, Crossley et al
150
found that the majority had an infection control committee (ICC) and a designated
ICP, although substantial deficiencies in resident and employee health programs occurred.
For instance, only 61% offered the influenza vaccine to residents, and one third did
not screen new employees for a history of infectious disease problems. A 1988 Maryland
survey
151
found that one third of nursing homes still performed routine environmental cultures,
and many lacked proper isolation policies. In 1990, a survey of Connecticut LTCFs
found that most ICPs had received some training in infection control.152, 153 Most
LTCFs performed surveillance at least weekly, and most used written criteria to determine
HAIs.
More recent regional surveys of facilities from Maryland and New England in the mid-1990s
and Michigan in 2005 noted increasing gains in time spent in infection control activities
from 1994 to 2005.69, 154 In New England, 98% of facilities had a person designated
to do infection control, 90% were registered nurses, and 52% had formal training.
154
In the 1990s, an average of 9 to 12 hours per week was spent on infection control;
50% to 54% of that time was spent on surveillance activities.
154
Seventy-eight to 97% percent of the LTCFs reported a systematic surveillance system.
69
Formal definitions were used by 95% of respondents; 81% used the McGeer criteria,
and 59% calculated infection rates.
154
All facilities reportedly used Universal Precautions in caring for their residents.
154
By 2005, 50% of responding facilities in Michigan had a full-time ICP.
69
The mean time spent on infection control activities by the infection control staff
varied from 40 hours per week for full-time ICPs to 15 hours per week for part-time
staff.
69
However, part-time ICPs did not necessarily supervise smaller facilities with fewer
subacute care beds or give fewer in-services than full-time staff.
Despite these improvements, the number of ICPs per nursing home bed is 4-fold fewer
than the number of ICPs available in acute care hospitals.
155
LTCF-based ICPs are more likely to assume noninfection control functions than acute
care ICPs regardless of bed size; in one survey, 98% of LTCF ICPs had other duties,
156
while in a Michigan survey, 50% of 34 LTCFs had full-time ICPs.
69
Many of these noninfection control functions include employee health, staff education
and development, and quality improvement.
155
In addition, LTCF ICPs are still less likely to receive additional formal training
in infection control (8%) compared with 95% of acute care ICPs.
155
The results of this study from Maryland led to a state proposal that at least one
ICP from each LTCF be formally trained in infection control.
155
From these surveys, one can develop a composite picture of the LTCF ICP as a nurse
who still has not necessarily received formal training in infection control.154, 155
Many ICPs still work part-time on infection control activities regardless of the number
of beds or patient acuity.69, 155 While the time spent on infection control activities
appears to have increased significantly from 36 to 48 hours per month in the 1990s
to 90 to 160 hours per month in 2005, the ICP continues to have other duties such
as general duty nursing, nursing supervision, in-service education, employee health,
and quality assurance.34, 69, 154
Regulatory aspects
LTCFs are covered by federal and state regulations as well as voluntary agency standards
such as those written by The Joint Commission (TJC).
157
Skilled nursing facilities are required by the Omnibus Budget Reconciliation Act of
1987 (OBRA) to have an infection control program.
158
CMS has published requirements for LTCFs
159
that apply to LTCFs accepting Medicare and/or Medicaid residents. CMS regulations
address the need for a comprehensive infection control program that includes surveillance
of infections; implementation of methods for preventing the spread of infections including
use of appropriate isolation measures, employee health protocols, hand hygiene practices;
and appropriate handling, processing, and storage of linens.160, 161 For example,
the LTCF is required to establish and maintain an infection control program designed
to provide a safe, sanitary, and comfortable environment and to help prevent the development
and transmission of disease and infection. Interpretive guidelines for surveyors further
discuss definitions of infection, risk assessment, outbreak management and control,
measures for preventing specific infections, staff orientation, antibiotic monitoring,
sanitation, and assessment of compliance with infection control policies.
161
Because the LTCF is an employer of health care workers (HCWs), it must comply with
federal and/or state OSHA regulations. For infection control, those regulations162,
163 deal primarily with protection of workers from exposure to bloodborne pathogens
such as HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) and from TB exposure.
85
Adherence of LTCFs to infection control regulations is an OSHA priority.
Other standards that apply to LTCFs include the federal minimum requirements for design,
construction, and equipment
164
and TJC LTC Standards.
165
The 2007 TJC Standards for LTC require a written infection control plan based on an
assessment of risk; establishment of priorities, goals, and strategies; and an evaluation
of the effectiveness of the interventions. The Standards also deal with managing an
influx of patients with an infectious disease as well as leadership's involvement
in the program.
165
In addition, many states have statutory requirements for LTCFs that vary widely.
On October 7, 2005, CMS published a final rule requiring LTCFs to offer annually to
each resident immunization against influenza and to offer lifetime immunization against
pneumococcal disease. LTCFs are required to ensure that each resident or legal representative
receive education on the benefits and potential side effects of the immunizations
prior to their being administered.
58
The LTCF administrative staff should be knowledgeable about the federal, state, and
local regulations governing infection control in order to implement and maintain a
program in compliance with these regulations. The LTCF ICP ideally should be involved
in the formation and revision of regulations, through local and national infection
control and long-term care organizations, to help assure the scientific validity of
the regulations.
Experts in infection control in Canada have called for 1 full-time formally trained
ICP per 150 to 250 long-term beds.
166
The Consensus Panel from SHEA and APIC has recommended that nonhospital facilities
including LTCFs provide adequate resources in terms of personnel, education, and materials
to ICPs to fulfill their functions.
167
While most of the current information has been derived from facilities serving older
populations in North America, reports from LTCFs in Europe and Australia and those
serving pediatric populations are increasing.168, 169, 170, 171
Infection control program elements
The structure and components of an infection control program are shown in Table 2,
Table 3
, respectively. Several authors have discussed the components of an infection control
program in the LTCF.34, 36, 166, 167, 172, 173, 174, 175, 176, 177 These components
generally are drawn from regulatory requirements, current nursing home practices,
and extrapolations from hospital programs. The limited resources of most LTCFs affect
the type and extent of programs developed.
173
Most authors feel that an infection control program should include some form of surveillance
for infections, an epidemic control program, education of employees in infection control
methods, policy and procedure formation and review, an employee health program, a
resident health program, and monitoring of resident care practices. The program also
may be involved in quality improvement, patient safety, environmental review, antibiotic
monitoring, product review and evaluation, litigation prevention, resident safety,
preparedness planning, and reporting of diseases to public health authorities.
Table 2
Long-term care facility infection control program: structure
Leadership
Expertise/training
Role(s)
Infection Control Committee/Oversight Committee
Core members
Administration, Nursing Representative, Medical Director, ICP
Identifies areas of risk
Ad hoc members
Food Service, Maintenance, Housekeeping, Laundry Services, Clinical Services, Resident
Activities, Employee Health
Establishes priorities
Plans strategies to achieve goals
Implements plans
Develops policies/procedures
Allocates resources
Assesses program efficacy at least annually
Infection Control Professional
ICP
Qualification via education, experience, certification
Surveillance
Data collection and analysis
Implementation of policies, procedures
Education
Reporting to oversight group/ICC
Communication to public health
Communication to other agencies
Communication to other facilities
Table 3
Long-term care facility infection control program: elements
Elements
Examples
Infection control activities
Establish and implement routine infection control policies and procedures
Hand hygiene
Standard precautions
Organism-specific isolation
Employee education
Infection identification
Develop case definitions
Establish endemic rates
Establish outbreak thresholds
Identification, investigation, and control of outbreaks
Organism-specific infection control policies and procedures
Influenza
TB
Scabies
MDROs (eg, MRSA)
Disease reporting
Public health authorities
Receiving institutions
LTCF staff
Antibiotic stewardship
Review of antimicrobial use
Monitoring of patient care practices
Aspiration precautions
Pressure ulcer prevention
Invasive device care and use
Facility management issues
General maintenance
Plumbing/ventilation
Food preparation/storage
Laundry collection/cleaning
Infectious waste collection/disposal
Environment
Housekeeping/cleaning
Disinfection/sanitation
Equipment cleaning
Product evaluation
Single use devices
Resident health program
TB screening
Immunization program
Employee health program
TB screening
Immunizations
Occupational exposures
Other program elements
Performance improvement
Serve on PI committee
Resident safety
Study preventable adverse events
Preparedness planning
Develop pandemic influenza preparedness plan
The ICP
An ICP is an essential component of an effective infection control program and is
the person designated by the facility to be responsible for infection control (see
Table 2), The ICP usually is a staff nurse, a background that is helpful for resident
assessment and chart review. The ICP most commonly is a registered nurse. Because
of size and staffing limitations, the vast majority of LTCF ICPs have other duties,
such as assistant director of nursing, charge nurse, in-service coordinator, employee
health, or performance improvement. The number of LTCF beds justifying a full-time
ICP is unknown and usually depends on the acuity level of residents and the level
of care provided. A LTCF with more than 250 to 300 beds may need a full-time ICP.
The LTCF ICP, like the hospital ICP, requires specific training in infection control;
well-defined support from administration; and the ability to interact tactfully with
personnel, physicians, and residents.
APIC and the Community and Hospital Infection Control Association-Canada (CHICA-Canada)
have developed professional and practice standards for infection control and epidemiology
that address education including qualifications and professional development for the
ICP.
178
These standards may not represent the current education and qualifications of ICPs
in many LTCFs, but they serve as a benchmark for which LTC ICPs and their facilities
can strive.
The qualifications include 3 criteria for entering the profession. The ICP:
•
Has knowledge and experience in areas of resident care practices, microbiology, asepsis,
disinfection/sterilization, adult education, infectious diseases, communication, program
administration, and epidemiology;
•
has a baccalaureate degree (the minimum educational preparation for the role); and
•
attends a basic infection control training course within the first year of entering
the profession.
The criteria for professional development include the ICP maintaining current knowledge
and skills in the area of infection prevention, control, and epidemiology. The professional
development standards include 5 criteria. The ICP:
•
Becomes certified in infection control within 5 years of entry into the profession
and maintains certification;
•
advances knowledge and skills through continuing education;
•
pursues formal education in health care epidemiology;
•
maintains a knowledge base of current infection prevention and control information
through peer networking, Internet access, published literature, and/or professional
meetings; and
•
advances the field of infection prevention and control and epidemiology through support
of related research.
The infection control oversight committee
The regulatory requirement for a formal LTCF ICC was dropped by OBRA at the federal
level, but some states still require them.
174
The ICP should be familiar with state regulations. This committee frequently has been
less active than the corresponding ICC in the hospital setting, in part because of
decreased physician availability. A small working group (the infection control oversight
committee) consisting of the ICP, the administrator, the medical director, and the
nursing supervisor or their designee may efficiently make most of the infection control
decisions (Table 2). The ICC functions may be merged with the performance improvement
or patient safety programs, but infection control must remain identifiable as a distinct
program. Whatever group is selected to oversee the infection control program, it should
meet regularly to review infection control data, review policies, and monitor program
goals and activities. Written records of meetings should be kept.
The LTCF administrative staff should support the ICP with appropriate educational
opportunities and resources, including expert consultation in infectious diseases
and infection control as needed. The participation of an infectious diseases (ID)
physician or other health care professional with training or experience in infection
control should be available on at least a consultative basis. Information may be obtained
from SHEA (www.shea-online.org or 703-684-1006). The local health department may have
useful information, and local ICPs are another valuable source of information, available
from the APIC at www.apic.org.
Educational opportunities for ICPs
Courses are available for ICPs and health care epidemiologists. SHEA offers jointly
sponsored courses in health care epidemiology and infection control for individuals
with different levels of experience. The SHEA/CDC course is for physicians and others
with advanced training who wish to increase their expertise in infection control.
The SHEA/Infectious Diseases Society of America (IDSA)/Johns Hopkins University School
of Medicine of America course is designed primarily for ID physicians in training.
Similar courses are offered in Europe through SHEA and the European Society for Clinical
Microbiology and Infectious Diseases (www.shea-online.org or 703-684-1006). APIC offers
a training course for hospital and LTCF infection control professionals (www.apic.org
or 202-789-1890). The Nebraska Infection Control Network offers regular 2-day basic
training courses specifically for LTCF ICPs (www.nicn.org), and other local courses
are available.
Surveillance
Infection surveillance in the LTCF involves the systematic collection, consolidation,
and analysis of data on HAIs. Standardization of surveillance is desirable. To facilitate
standardization, resources that include practice guidance for surveillance identifying
seven recommended steps are available. These steps are (1) assessing the population,
(2) selecting the outcome or process for surveillance, (3) using surveillance definitions,
(4) collecting surveillance data, (5) calculating and analyzing infection rates, (6)
applying risk stratification methodology, and (7) reporting and using surveillance
information.
179
Assessing the population. Infection surveillance may either include all residents
in a facility (total house surveillance) or be targeted at specific subpopulations.
Although facility-wide surveillance is useful for calculating baseline rates and detecting
outbreaks, a more focused analysis could include examination of infection rates in
residents who are at risk for certain kinds of infection (such as aspiration pneumonia
in residents receiving tube feedings or bloodstream infection among residents with
indwelling vascular catheters). Focused surveillance should target infections that
are preventable; that occur frequently; and that are associated with significant morbidity,
mortality, and cost. Facility-wide surveillance is useful for establishing an infection
control “presence” in the LTCF and may be required as a part of local or state regulatory
programs. To establish baseline infection rates, track progress, determine trends,
and detect outbreaks, site-specific rates should be calculated (eg, central line infections
per 1000 central line-days). Routine analysis should try to explain the variation
in site-specific rates. For example, a change in the rate might be related to a change
in the resident population. Focused or high-risk resident surveillance may permit
conservation of resources, although in many small institutions whole house surveillance
is feasible.
Selecting the outcome measures. Traditionally surveillance in the LTCF refers to collection
of data on outcome measures such as HAIs that occur within the institution (eg, incidence
of UTI or central line-associated bacteremia). These surveillance data are used primarily
to guide control activities, to plan educational programs, and to detect epidemics,
but surveillance also may detect infections that require therapeutic action.
Process measures (eg, surveillance of infection control practices) should also be
part of the infection control and quality improvement programs and may be very helpful
in identifying areas for improvement in practice and for monitoring compliance with
regulatory aspects of the infection control program. Examples of process measures
include observation of hand hygiene compliance, observation of correct catheter care
technique, antibiotic utilization studies, timeliness in administering and reading
TB skin tests, and administration of hepatitis B immunization to new employees within
10 working days of hire.
Using surveillance definitions. Surveillance requires objective, valid definitions
of infections. Most hospital surveillance definitions are based on the National Nosocomial
Infections Surveillance System (NNIS) criteria,
180
but no such standard exists for long-term care. NNIS (now the National Healthcare
Safety Network [NHSN]) definitions depend heavily on laboratory data and recorded
clinical observations. In the LTCF, radiology and microbiology data are less available,
and written physician notes and nursing assessments in the medical record usually
are brief. Timely detection of HAI in the LTCF often depends on recognition of clues
to infection by nurses' aides and reporting of these findings to the licensed nursing
staff.
181
Positive cultures do not necessarily signify infection.
Modified LTCF-specific surveillance criteria were developed by a Canadian consensus
conference. These definitions were designed in light of some of the unique limitations
of nursing home surveillance mentioned previously. They are used widely, although
they have not yet been validated in the field.
23
Collecting surveillance data. Published LTCF surveys have been either incidence or
prevalence studies. Prevalence studies detect the number of existing (old and new)
cases in a population at a given time, whereas incidence studies find new cases during
a defined time period. The latter is preferred because more concurrent information
can be collected by an incidence study if data are collected with regularity.
The surveillance process consists of collecting data on individual cases and determining
whether or not a HAI is present by comparing collected data to standard written definitions
(criteria) of infections. One recommended data collection method in the LTCF is “walking
rounds.”
182
This is a means of collecting concurrent and prospective infection data that are necessary
to make infection control decisions. Surveillance should be done on a timely basis,
probably at least weekly.
183
During rounds, the ICP may use house reports from nursing staff, chart reviews, laboratory
or radiology reports, treatment reviews, antibiotic usage data, and clinical observations
as sources of information.
Analysis and reporting of surveillance data. Analysis of absolute numbers of infections
is misleading; calculation of rates provides the most accurate information. Rates
are generally calculated by using 1000 resident-days as the denominator. In the past,
average daily census has sometimes been used as the denominator, but resident-days
more clearly reflect resident risk.
Infection control data, including rates, then need to be displayed and distributed
to appropriate committees and personnel (including administration) and used in planning
infection control efforts. The data should lead to specific interventions such as
education and control programs.
To compare rates within a facility or to other facilities, the method of calculation
must be identical (including the denominator). Even when calculation methods are consistent,
infection rates may differ between facilities because of different definitions of
infection or differences in resident risk factors and disease severity, and thus comparisons
may not be valid. Comparison of infection rates between facilities, for public reporting
or other purposes, requires control of definitions and collection methods, severity
adjusting and data validation.
184
The use of a regional data set may allow for more meaningful intrafacility comparison
of infection rates.
185
This may also allow for interfacility comparisons of infection rates across a corporation
or geographic area.
18
Analysis and reporting of infection data usually are done monthly, quarterly, and
annually to detect trends. This process is facilitated by an individual infection
report form, samples of which have been published.36, 186, 187 The statistics used
in analysis of data need not be complex. Computerization for sorting and analysis
of data may be timesaving for larger programs, and software for use on a personal
computer is available. Graphs and charts facilitate presentation and understanding
of infection control data and also may be facilitated by computer programs. The commercially
available programs may help with analysis of surveillance data, but manual data collection
is still usually necessary.
The feasibility of routine surveillance in LTCFs has been demonstrated, and data have
been used to provide a basis for continuing education.
188
Surveillance needs to be simple and pragmatic, particularly because the LTCF ICP may
be able to spend only a few hours per week on infection control activities.
181
Outbreak control
Outbreak surveillance and control should be considered a high priority for ICPs. The
leading causes of LTCF outbreaks are discussed above and listed in Table 1. When the
number of cases exceeds the normal baseline, an outbreak within the facility should
be considered. The ICP is advised, and required by CMS, to monitor resident and staff
illnesses, since healthy personnel may acquire and transmit virulent pathogens.
For many, the word outbreak means a dramatic clustering of cases of an infectious
disease in a geographic area over a relatively short period of time. However, the
threshold for declaring an outbreak and initiating control measures may be much lower.
For example, we know that influenza may cause explosive outbreaks in nursing homes.
59
Public health officials have, therefore, set low thresholds for identifying an outbreak
if influenza is suspected so that outbreak control strategies can be implemented to
avoid high attack rates. The CDC recommends defining a nursing home outbreak of influenza
as a single laboratory-confirmed case or a sudden increase of acute febrile respiratory
illness over the normal background rate.
189
Special outbreak control measures may, therefore, be appropriate if there is evidence
of transmission of an epidemiologically important pathogen within the facility rather
than waiting for a fully evolved clinical outbreak.
For TB, an outbreak investigation should be triggered by a single active case. TB
outbreaks are often caused by a single case and may infect large numbers of residents
and staff by the airborne route before detection.74, 190 In addition, a single infection
caused by Legionella spp, scabies, Salmonella spp, or other GI pathogens associated
with outbreaks should trigger an evaluation. A single case of Legionella spp may signal
colonization of the water supply.
123
The approach to investigating an outbreak includes (1) determining that an outbreak
has occurred, (2) developing a case definition, (3) case finding, (4) analyzing the
outbreak, (5) formulating a hypothesis regarding mechanism of transmission, (6) designating
control measures, and (7) evaluating control measures. A CDC SHEA publication is available
to guide investigation of outbreaks.
191
Given the fact that influenza and norovirus outbreaks are relatively common, clinical
case definitions should be developed in advance and placed in preexisting policies
and procedures. To facilitate rapid implementation of control measures, the charge
nurses should be empowered by preexisting policies to rapidly isolate and/or cohort
infected individuals and to curtail contact between residents and staff on units in
an outbreak situation.
The LTCF may have difficulty responding to an epidemic with appropriate measures (such
as mass vaccination or administration of antivirals during an influenza outbreak)
if consent needs to be obtained on short notice from a resident's decision maker or
primary physician. One way to circumvent this problem is to develop preexisting policies
and procedures approved by the medical staff and to obtain consent for vaccination
and outbreak control measures at the time of admission from the resident or their
power of attorney/medical decision maker.
Isolation and precautions: Importance and evolution
Prevention of transmission of significant pathogens to patients and HCWs is the major
goal of isolation within health care systems. There are very limited data on the impact
of isolation and infection control precautions, however, on the transmission of pathogens
within LTCFs. The high prevalence of risk factors for infection among LTCF residents,
the high colonization rate of MDROs in skilled care units, and the frequent reports
of LTCF infectious disease outbreaks support the need for appropriate infection control
in that setting.
136
A unique infection control challenge for the LTCF is the mobile resident, who may
be confused or incontinent and serves as a possible vector for infectious diseases.
7
The presence of MDROs in the LTCF has implications beyond the individual facility.
Because residents of LTCFs are hospitalized frequently, they can transfer pathogens
between LTCFs and receiving hospitals; transfer of patients colonized with MDROs between
hospitals and LTCFs has been well documented.192, 193 On the other hand, LTCF residents
remain in the facility for extended periods of time, and the LTCF is functionally
their home. An atmosphere of community is fostered, and residents share common eating
and living areas and participate in various activities. Thus, the psychosocial consequences
of isolation measures must be carefully balanced against the infection control benefits.
Isolation recommendations from the CDC have been available since 1970 but have specifically
been targeted towards acute care settings. ICPs in the LTCF have thus been required
to adapt these practices to their individual settings. Traditionally, 2 types of systems
for implementing barrier precautions in the hospital were promoted. A Category-Specific
System listed 7 categories of isolation or precautions based on means of disease transmission:
strict isolation, contact isolation, respiratory isolation, TB isolation, enteric
precautions, drainage and secretion precautions, and blood and body fluid precautions.
Modifications of this approach have been promoted since 1970 with a refined Category-Specific
System in the 1983 recommendations.194, 195 A Disease-Specific System listed all relevant
contagious diseases and the recommended barrier method. In general, the Category-Specific
System was simpler to use, but the Disease-Specific System consumed fewer resources
because precautions were tailored to the specific disease. In the 1983 guideline,
blood precautions were expanded to include body fluids.
195
In response to the HIV/AIDS epidemic, the concept of Universal Precautions was introduced
to protect HCWs from all bloodborne exposures.196, 197 These recommendations became
adopted by OSHA and have thus been applicable to all health care settings including
LTCFs.163, 198 In this system, all blood and certain body fluids are considered potentially
infectious. Education, provision of needle-disposal units, provision of protective
equipment (such as gloves, gowns, and protective eye wear), and monitoring compliance
were part of Universal Precautions, although it alone was not considered a complete
isolation system.
CDC isolation guidelines released in 1996 integrated earlier isolation systems by
introducing transmission-based precautions.
199
Standard Precautions replaced Universal Precautions and were to be applied to all
patients. Standard Precautions emphasize hand hygiene, gloves (when touching body
fluids), masks, eye protection, and gowns (when contamination of clothing is likely),
as well as avoidance of needlestick and other sharps injuries. More specific isolation
was recommended for patients with documented or suspected contagious pathogens. These
include Airborne Precautions (eg, for varicella, measles, and TB), Droplet Precautions
(eg, for influenza and other respiratory infections), and Contact Precautions (eg,
for MRSA,VRE, and C difficile diarrhea).
CDC and HICPAC have recently released 2 infection control guidelines that have application
in this regard to LTCFs. The first one released focuses specifically on the management
of MDROs in health care settings, and the second is an update to previously recommended
general isolation precautions from 1996 guidelines.200, 201 Respiratory hygiene/cough
etiquette and safe injection practices were added as new elements of Standard Precautions.
Most LTCFs do not have negative-pressure rooms for Airborne Precautions, and residents
with suspected TB should be transferred to facilities where such units exist.
Isolation and precautions: MDROs
The majority of the infection control literature on MDROs in the LTCF has focused
on MRSA, but these guidelines may also apply if a facility recognizes significant
problems with other MDROs such as VRE or antibiotic-resistant, gram-negative bacilli.
Barrier precautions are important in preventing cross infection with known resistant
microorganisms, but approaches to isolation of LTCF patients colonized or infected
with MDROs vary substantially across facilities.69, 156
Most LTCFs employ at least some type of isolation for MDROs.202, 203 It was found
that 90.5% of facilities accepting patients with MRSA stated that they followed Contact
Precautions despite only 39.7% placing them in private rooms.
202
In another survey, most LTCFs in Nebraska were aware of and often screened for MRSA
and employed some precautions in dealing with these residents (eg, single room, cohorting,
contact isolation, or placing the resident with MDRO in the same room as a low-risk
roommate).
203
Another study demonstrated no difference in transmission of MDROs in a skilled care
unit between contact isolation precautions and routine glove use.
204
The authors suggested that universal glove use may be preferable to contact isolation
because it reduces social isolation for LTCF residents where their health care facility
is also their home. Others have suggested a “modified” contact isolation protocol
as often more appropriate in the LTCF setting.
205
Clearly, additional evidence-based studies defining the specific isolation needs within
LTCF are needed.
General guidelines for control of MRSA
148
and VRE
206
are published but emphasize hospital settings. These guidelines serve as an appropriate
starting point for adapting an LTCF approach. There are many reports of aggressive
infection control measures containing MDROs in the hospital setting.
200
However, data in the LTCF are very limited, and implementation of isolation procedures
identical to those found in a hospital may result in undesirable social and psychological
consequences and functional decline for residents.
207
SHEA position papers on antimicrobial resistance and infection control specifically
address the LTCF208, 209 and discuss prescreening admissions for resistant bacteria,
surveillance for resistant bacteria, and endemic resistance.
The recent HICPAC isolation guidelines attempt to address some of the specific needs
and concerns of the LTCF.200, 201 The principles in both documents can be adopted
for use in the LTCF setting. The MDRO document discusses general control interventions
such as administrative support, education of HCWs, surveillance, and judicious use
of antimicrobial agents (see Antibiotic stewardship section below) that are applicable
in the LTCF setting. LTCFs are encouraged to identify experts who can provide consultation
for analyzing surveillance data and devising effective infection control strategies
to control MDROs. The development of laboratory protocols for storing bacterial isolates
for molecular typing when needed to understand the epidemiology of transmission is
recommended. When the LTCF laboratory has contracted with an off-site laboratory,
the facility will need to develop an arrangement for storing and testing isolates.
The guidelines200, 201 recommend continuing the use of transmission-based isolation
precautions. In LTCFs, it is advised to consider the individual resident's clinical
situation when deciding whether to implement or modify the use of Contact Precautions
in addition to Standard Precautions if colonized or infected with a MDRO. Standard
Precautions are sufficient for relatively healthy and independent residents, ensuring
that gloves and gowns are used for contact with uncontrolled secretions, pressure
ulcers, draining wounds, stool, and ostomy tubes/bags.
Contact Precautions are indicated for residents with MDROs who are ill and totally
dependent upon HCWs for activities of daily living or whose secretions or drainage
cannot be contained. Single rooms for these residents are recommended if available.
The cohorting of MDRO residents is acceptable if single rooms are not available. If
cohorting is not possible, then placing residents with MDRO with residents who are
low risk for acquisition or with anticipated short lengths of stay is advised. While
“low risk for acquisition” of an MDRO has not been officially defined, one source
suggested that it should include residents who are not immunosuppressed; not on antibiotics;
and free of open wounds, drains, and indwelling urinary catheters.
209
Case-by-case decisions, as needed, can be made regarding the best precautions to use
for each resident with a MDRO. With Contact Precautions, wearing a gown and gloves
for all interactions that may involve contact with the resident and their environment
is advised, and eye protection is recommended when there is risk of splash or spray
of respiratory or other body fluids.
Recommendations for minimizing antibiotic resistance also include using appropriate
barrier precautions for MDROs, maintaining a line listing of residents infected or
colonized with MDROs, and not attempting eradication of MDROs from colonized residents.
208
It is not recommended that the LTCF refuse MRSA or VRE cases but develop an institutional
strategy for control of the resistant organisms based on local considerations.133,
148, 208, 210
In summary, elements of routine MDRO control for the LTCF include monitoring MRSA
and VRE culture results, communicating MDRO data to health care providers, including
routine communication about MDROs at in-services, assessing compliance with isolation
precautions and hand hygiene, monitoring antimicrobial usage, notifying receiving
or transmitting facilities of the presence of a MDRO, designating residents previously
known to be infected or colonized with MDROs, and instituting adequate environmental
cleaning. If a MDRO problem exists in a LTCF and is not controlled with these basic
infection control practices, then additional control measures are indicated. These
include consultation from experts, intensification of education, increased efforts
to control antimicrobial use, active surveillance cultures, point-prevalence culturing
of targeted units, intensification of isolation with compliance assessment, and monitoring
environmental cleaning.
Isolation and precautions: Bloodborne pathogen issues
LTCFs may be asked to provide care for persons with hepatitis C, hepatitis B, HIV,
and acquired immunodeficiency syndrome (AIDS), especially for individuals with advanced
disease who are too ill to reside at home but do not require acute hospital care.
Earlier guidelines for dealing with HIV infection in the health care setting are incorporated
widely in hospitals but also apply in the LTCF.197, 199 The standard approaches to
protecting HCWs and other patients from transmission of bloodborne pathogens have
essentially not changed since these earlier recommendations. In the current isolation
guidelines,
201
Standard Precautions are still promoted as the main method for preventing exposure
to blood and body fluids for all patient interactions. These include the routine use
of hand hygiene, gloves, gowns, masks, and eye protection, depending upon the anticipated
exposures.
The guideline also discusses in detail safe work practices to prevent exposures to
bloodborne pathogens, including prevention of needlesticks and other sharp-related
injuries; prevention of mucous membrane contact; safe injection practices; and precautions
during aerosol-generating procedures. Infection control personnel at all LTCFs should
carefully review these guidelines and develop a plan for implementation within their
facilities. As in hospitals, it is known that needlestick injuries do occur in the
LTCF and usually are related to needle recapping.
211
Plans for regular education of all staff and for compliance with OSHA standards should
be in place, and LTCFs should ensure the availability to hepatitis B vaccination and
postexposure prophylaxis for HIV or hepatitis B for all employees in accordance with
the most recent guidelines.
212
Hand hygiene
Hand hygiene likely remains the most important infection control measure in the LTCF
as well as in the hospital. Unfortunately, poor compliance with hand hygiene recommendations
has been noted in LTCFs, as in other settings.213, 214 Health care provider hand contamination
is usually transient and amenable to hand hygiene,
215
frequent hand hygiene would be expected to lower LTCF infection rates,203, 216 and
the availability of alcohol-based hand sanitizer dispensers enhances access to hand
sanitizing agents.
CDC and HICPAC published a comprehensive hand hygiene guideline.
217
Other published guidelines for hand hygiene and choice of antiseptic agents are also
applicable.218, 219 They recommend the use of bar or liquid soap when hands are visibly
dirty or contaminated with proteinaceous material or visibly soiled with blood or
other body fluids. If hands are not visibly soiled, then the routine use of an alcohol-based
hand rub is recommended in the LTCF. Hands should always be decontaminated after the
removal of gloves. Hand hygiene with an antiseptic agent or alcohol-based hand rub
is recommended before donning sterile gloves for performing invasive procedures such
as placement of an intravenous or urinary catheter. Hand hygiene compliance should
be monitored by the facility.
Resident health
Resident health programs are recommended for prevention of infections,
7
but comprehensive programs often are lacking in LTCFs.
149
One of the major functions of a resident health program is the immunization of the
elderly resident.59, 220, 221 The elderly are underserved in terms of immunization
to tetanus,
222
as well as pneumococcal and influenza vaccines.
223
They should receive pneumococcal vaccine at age 65, when they are relatively immunologically
responsive, rather than at age 80 to 85 when entering the LTCF.
57
Standing orders for influenza and pneumococcal vaccination are associated with improved
vaccination rates.
224
Residents should receive a TB skin test on admission and undergo chest radiograph
if TST positive or symptomatic.
78
Other resident care practices that should be addressed include resident hand hygiene,
oral hygiene, prevention of aspiration, skin care, and prevention of UTIs. Clinical
trials in LTCFs have reported no decrease in infections with routine vitamin or mineral
supplementation.225, 226 However, optimal care of comorbid illnesses and good nutrition
are principles of care irrespective of impact on infections.
Employee health
Published information on infection control in hospital personnel is available.227,
228, 229 Employee infection prevention considerations in the LTCF are somewhat different
than in the hospital, but the published literature and guidelines generally apply
to the LTCFs as well as hospitals. Because of congregate living conditions in most
LTCFs, there are some notable differences including an increased risk of exposure
to residents with herpes zoster, scabies, conjunctivitis, influenza, TB, and viral
gastroenteritis. The pediatric LTCF offers additional challenges to the prevention
of infection including childhood diseases, such as varicella, measles, mumps, and
rubella.
Regulations concerning protection of employees from bloodborne pathogens apply to
the LTCF.163, 196 The LTCF should be able to provide timely chemoprophylaxis to employees
who may have blood/body fluid exposure to residents known to have HIV.
212
Employee health policies and procedures should address postexposure follow-up or prophylaxis
for certain infections, such as hepatitis B, hepatitis C, TB, scabies, and HIV.
Primary employee vaccination considerations should include influenza, hepatitis B,
tetanus/diphtheria, and pertussis. Varicella, measles, mumps, rubella, and hepatitis
A are of greater concern in the pediatric LTCF setting. Influenza vaccine campaigns
should require signed declination statements by employees who decline vaccination.
230
Adult vaccination information can be found at http://www.immunize.org/. Vaccination
should include hepatitis B to protect from this bloodborne pathogen. Varicella vaccine
is appropriate if an employee is not immune. Hepatitis A vaccine may be appropriate
in certain circumstances, especially in behavioral health and developmental disability
facilities. Vaccine Information Sheets (VIS) should be given to all adult vaccinees
as required by the National Childhood Vaccine Injury Act (42 U.S.C. §300aa-26). Anaphylaxis
or any other adverse event requiring medical attention within 30 days after receipt
of a vaccine must be reported to the Vaccine Adverse Events Reporting System (VAERS),
a requirement of the National Vaccine Injury Compensation Program (www.vaers.org/pdf/vaers_form.pdf).
Initial assessment of employees and education in infection control also are important,
as is a reasonable sick-leave policy.
150
Ill employees may cause significant outbreaks in the LTCF.
124
Initial screening should include TB, also required by some states.231, 232 LTCFs are
required to prohibit employees with communicable diseases or infected skin lesions
from direct contact with residents and to prohibit employees with potentially infectious
skin lesions from contact with residents' food.
159
Education
The value of education of the LTCF ICP has long been recognized, and surveys of personnel
confirm this need.
233
The importance of ICP education is accentuated by the great turnover in LTCF personnel.
While the benefits of ICP training are widely assumed, one study analyzed the effects
of a 2-day, intensive basic training program on 266 ICPs.234, 235 Trainees not only
demonstrated an increase in postcourse knowledge but, at 3- and 12-month follow-up,
had a significant increase in implementation of key infection control practices. Practices
included performance of surveillance, using infection definitions, calculating infection
rates, and giving employees and residents TST and influenza vaccine.
The role of education in infection prevention in the LTCF extends well beyond the
ICP. One of the most important roles of the ICP is education of LTCF personnel in
basic infection control principles. It is recommended that the ICP routinely assess
the educational needs of staff, residents, and families and develop educational objectives
and strategies to meet those needs; collaborate in the development, delivery, and
evaluation of educational programs or tools that relate to infection prevention, control,
and epidemiology; and continuously evaluate the effectiveness of educational programs
and learner outcomes.
Education should focus on new personnel and certified nursing assistants.
186
Priority for training should be directed toward orientation, OSHA-mandated programs,
problem-oriented teaching, and other programs required by regulations. Surveillance
data are an excellent starting point for infection control training, and compliance
rounds provide an opportunity for the ICP to provide timely, informal education to
personnel. Infection control content should include information on disease transmission,
hand hygiene, barrier precautions, and basic hygiene.
234
In addition, all individuals with direct resident care responsibility need education
in early problem and symptom recognition. The teaching methods used need to be sensitive
to language, cultural background, and educational level. A coordinated, effective
educational program will result in improved infection control activities.
235
Antibiotic stewardship
Antibiotic-resistant bacteria pose a significant hazard in the LTCF, and this resistance
has been strongly associated with antibiotic use.136, 236, 237, 238, 239, 240 Antimicrobials
are among the most frequently prescribed medications in the LTCF.
241
Antibiotics are given to approximately 7% to 10% of residents in LTCFs, frequently
for lengthy periods of time.242, 243, 244 A study of 22 LTCFs noted an incidence of
antibiotic prescriptions of 2.9 to 13.9 antibiotic courses per 1000 resident-days.
245
Several studies have questioned the appropriateness of this practice.242, 243, 244
A common problem is the failure to distinguish infection and colonization (such as
a positive swab culture of a pressure ulcer or a urine culture showing bacteriuria
without signs or symptoms of infection) and the treatment of the colonization with
antibiotics. In addition, antibiotics often are prescribed over the telephone in this
setting.
246
There also appears to be significant variability in antibiotic prescribing patterns
in the LTCF.
247
Several reviews and guidelines for infection control efforts to curb antibiotic resistance
in health care settings (including LTCFs) have been published.167, 173, 200 These
guidelines stress the importance of having an ICP trained in infection control and
LTCF administrative support and resources for the infection control program.
237
The CDC has published a 12-step program for preventing antimicrobial resistance among
LTCF residents that addresses the broad areas of preventing infection (eg, resident
vaccination), diagnosis/treatment of infection, using antibiotics wisely, and preventing
transmission (www.cdc.gov). A LTCF antibiotic review program is recommended
173
and is often found in LTCFs.248, 249
Recent guidelines have addressed the development of antimicrobial stewardship programs
in hospitals.
250
Using this guideline as a starting point, LTCFs are encouraged to include antimicrobial
stewardship in the LTCF infection control program and discuss appropriate choices
for various clinical situations.
241
A recent survey revealed that fewer than one third of LTCFs surveyed had any such
antibiotic use protocols in place.
251
Minimum criteria for initiation of antibiotic therapy have been proposed to improve
antimicrobial prescribing in LTCFs
252
and may be of assistance in developing antibiotic appropriateness criteria.
Approximately two thirds of LTCF professionals identified a clear need for greater
education regarding judicious antibiotic use in LTCFs.
251
Education and development of antibiotic guidelines have improved antimicrobial usage
in the LTCF setting in several studies.253, 254
Other aspects of the program
Policies and procedures
An important aspect of infection control programs is the development and updating
of infection control policies and procedures. Because practices change, they should
be reviewed on a scheduled basis. Review of the Bloodborne Pathogens Exposure Control
Plan is required to be done annually.
163
Resources are available on the writing of policies and procedures in general255, 256
dietetic service policies,
255
laundry policies,
257
physical therapy policies,255, 258, 259 and handwashing.217, 218, 219 Respiratory
therapy issues may be relevant to the LTCF, including cleaning of humidifiers, respiratory
therapy equipment, suctioning technique, and tracheotomy care.
36
Pharmacy and medication issues include use of multidose medication vials and resident
specific creams and ointments.
A policy and procedure on hand hygiene are critically important to have available
for staff.
217
The policy details specific indications for hand hygiene, including when coming on
duty; whenever hands are soiled; after personal use of toilet; after blowing or wiping
nose; after contact with resident blood or body secretions; before performing any
invasive procedures on a resident; after leaving an isolation room; after handling
items such as dressings, bedpans, catheters, or urinals; after removing gloves; before
eating; and on completion of duty. The corresponding procedure should list explicit
steps in the hand hygiene process. A 15-second handwash is usually recommended.36,
219 Alcohol-based hand rubs should be made available and used by staff, especially
when handwashing facilities are inadequate or inaccessible. Hand hygiene compliance
should be monitored.
217
Facility management
Environmental control in the facility is an important consideration. Routine environmental
cultures are not cost-effective and do not usually generate information relevant to
clinical infections. However, periodic environmental compliance rounds are recommended.186,
258 Sources are available suggesting specific environmental measures such as dishwasher
and laundry cleaning temperatures,186, 258, 260 although limited data exist.
A related area of concern is sterilization, disinfection, and asepsis, including the
evaluation of cleaning methods, such as monitoring reuse of disposable equipment.
Resources are available.261, 262 An infection control program should also monitor
basic hygiene (eg, respiratory etiquette) and compliance with proper infection control
techniques. Staff, residents, and families may all be the source of HAIs if there
is a breakdown in basic hygiene.
Selection of proper disinfectants and antiseptics requires infection control expertise.
Reading the manufacturer's label directions and following the required dilution and
contact time instructions are recommended. Infection control input will also be needed
on additional and new products that affect infection prevention, such as urinary catheter
systems, gloves, and disposable diapers. Quality, efficacy, and cost issues need to
be weighed in product selection.
263
Waste management is the important in the LTCF. Medical and biohazardous waste issues
are controversial; Environmental Protection Agency (EPA) regulations, OSHA regulations,
and CDC recommendations may conflict.
264
Local health department regulations should also be checked. Several resources are
available on medical waste issues relevant to the LTCF.162, 255, 258, 260, 264, 265
Disease reporting
Another important function of the infection control program is disease reporting to
public health authorities. State and local health departments will provide a list
of reportable diseases and other public health resources.
Performance improvement/resident safety
The increased emphasis on quality indicators in health care is becoming evident in
LTC. There are important differences in definitions of infection published for LTCF
surveillance (see Surveillance section above) and those in the long-term care Minimum
Data Set (MDS) manual. This is especially important for UTIs. In addition, CMS provides
a Web site called Nursing Home Compare,
58
which posts information to the public on nursing home quality measures, inspections,
staffing, and other data for individual LTCFs. For instance, UTI in the CMS MDS requires
a physician diagnosis in the chart and a positive urine culture.
266
This definition has been found to be inaccurate compared with standard definitions
such as the McGeer definition,
23
which requires a combination of symptoms and signs.
267
A quality assessment and assurance committee is required.
159
Infection control is the prototype quality improvement or performance improvement
(PI) program, and many of the techniques used in infection control are directly applicable
to PI, such as data collection, data analysis, and intervention.268, 269 The traditional
performance improvement process focuses on adverse events and assesses functions of
the system.270, 271 In the course of performing infection surveillance, there is ample
opportunity to monitor compliance with infection control policies and procedures and
to provide informal infection control education to address observed problems.
Examples of appropriate quality indicators for PI study include resident immunization
with influenza and pneumoccoccal vaccines,
272
employee vaccination for influenza,
273
number of employee TST conversions, and employee hand hygiene compliance. A national
focus on patient safety and prevention of adverse events has relevance to the LTC
setting as well.
274
Preparedness planning
The ICP will frequently play a key role in LTCF preparedness planning. The planning
is currently focused on pandemic influenza but should prepare the LTCF for dealing
with a variety of disaster scenarios. Issues to be considered include surge capacity,
medication availability and rationing, stockpiling, staff shortages during an influenza
pandemic, and communication with public health authorities for planning purposes.275,
276 It appears that the LTCF ICP will play an important role in preparedness and that
about half of LTCFs have a pandemic influenza plan.
277
Resources
Having appropriate job-related resources is essential to good performance in the role
of infection prevention and control. A few resources for the ICP are listed below:
1
Smith PW, editor. Infection control in long-term care facilities. 2nd ed. Albany,
NY: Delmar Publishers, Inc (800-347-7707); 1994. Cost, $38.95.
2
APIC infection connection: long-term care facilities newsletter. Available from the
Association for Professionals in Infection Control and Epidemiology (202-296-2742).
Cost for nonmembers, $15.
3
Strausbaugh LJ, Joseph C. Epidemiology and prevention of infections in residents of
long-term care facilities. In: Mayhall CG, editor. Hospital epidemiology and infection
control. Baltimore, MD: Williams & Wilkins (800-6380672); 2004. Cost, $199.
4
Heymann DL, editor. Control of communicable diseases manual. 18th ed. Washington,
DC: American Public Health Association; 2004. Cost, $33.00.
5
Horan-Murphy E, Barnard B, Chenoweth C, Friedman C, Hazuka B, Russell B, et al. APIC/CHICA-Canada
infection control and epidemiology: professional and practice standards. Am J Infect
Control 1999;27:47-51.
6
McGeer A, et al. Definitions of infection for surveillance in long-term care facilities.
Am J Infect Control 1991;19:1-7.
7
APIC text of infection control and epidemiology. Washington, DC: Association for Professionals
in Infection Control and Epidemiology, Inc.; 2005.
8
Nicolle LE, Garibaldi RA. Infection control in long-term care facilities. Infect Control
Hosp Epidemiol 1995;16:348-53.
Recommendations
See Table 4
for scoring scheme.
Table 4
Categorization of recommendations
In this document, as in a number of published HICPAC, SHEA, and APIC guidelines, each
recommendation is categorized on the basis of existing scientific evidence, theoretical
rationale, applicability, and national or state regulations. The following categorization
scheme is applied in this guideline:
Category IA. Strongly recommended for implementation and strongly supported by well-designed
experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by some experimental,clinical,
or epidemiologic studies and by strong theoretical rationale.
Category IC. Required for implementation, as mandated by federal or state regulation
or standard.
Category II. Recommended for implementation and supported by suggestive clinical
or epidemiologic studies or by theoretical rationale.
No Recommendation. Unresolved issue. Practices for which insufficient evidence or
no consensus regarding efficacy exists.
A. Infection control program
1
An active, effective, facility-wide infection control program should be established
in the LTCF. The purpose of the program is to help prevent the development and spread
of infectious diseases (Category IC).
Comment: The elements of a program generally include the following:
a. Surveillance—Systematic data collection to identify infections in residents
b. Outbreak Control—A system for detection, investigation, and control of epidemic
infectious diseases in the LTCF
c. Isolation—An isolation and precautions system to reduce the risk of transmission
of infectious agents
d. Policies and procedures—Relevant to infection control (see Table 2)
e. Education—Continuing education in infection prevention and control
f. Resident health program
g. Employee health program
h. Antibiotic stewardship—A system for antibiotic review and control
i. Disease reporting to public health authorities
j. Facility management, including environmental control, waste management, product
evaluation and disinfection, sterilization and asepsis
k. Performance improvement/resident safety
l. Preparedness planning
2
The infection control program must be in compliance with federal, state, and local
regulations (Category IC).
B. Infection control administrative structure
1
Oversight of the infection control program should be defined and should include participation
of the ICP, administration, nursing staff, and physician staff (Category II).
Comment: A committee, traditionally the ICC (infection control committee), may oversee
the infection control program for the facility. ICC members often include the ICP;
the medical director; and representatives from nursing, administration, and pharmacy.
Participation of other departments, such as dietary, housekeeping, and physical therapy,
should be considered on an ad hoc basis. Administrative structures other than an ICC
may provide oversight to the infection control program. One example is an infection
control oversight committee, a small group consisting of the LTCF administrator, the
ICP, and the medical director. Alternatively, the performance improvement committee
or patient safety committee and the ICC may be combined, but it is important to maintain
the identity of the infection control program. The duties of the ICC should be delegated
appropriately if no formal ICC exists.
2
Formal delegation of infection control oversight should be made in writing (Category
II).
3
The infection control oversight committee should meet on a regular basis and have
a mechanism for emergent meetings as needed (Category II).
4
This committee should maintain written minutes with identification of problems and
plans for action (Category II).
5
The effectiveness of the infection control program should be evaluated by the administration
on at least an annual basis (Category II).
6
Policies and procedures for investigating, controlling, and preventing infection transmission
in the facility should be established (Category IC).
Comment: Other functions include (a) review of infection control data, (b) approval
of policies and procedures, (c) monitoring program activities, and (d) recommending
policy to the facility administration.
7
Consultation should be available as needed including with an infectious disease physician
or other professional with expertise in infection control (Category II).
C. ICP
1
One person, the ICP, should be assigned the responsibility of directing infection
control activities in the LTCF. The ICP should be someone familiar with LTCF resident
care problems (Category IC).
2
The ICP should have a written job description of infection control duties (Category
II).
3
The ICP is responsible for implementing, monitoring, and evaluating the infection
control program for the LTCF (Category II).
4
The ICP should be guaranteed sufficient time and the support of the administration
to effectively direct the infection control program (Category II).
5
The ICP (or another appropriate individual, such as the medical director) should have
written authority to institute infection control measures in emergency situations
(Category IB).
6
The ICP should have a sufficient infection control knowledge base to carry out responsibilities
appropriately (Category II).
Comment: A background in infectious diseases, microbiology, geriatrics, and educational
methods is advisable. Management and teaching skills also are helpful. Continuing
education is essential for the ICP (eg, meetings, courses, journals).
7
The ICP should know the federal, state, and local regulations dealing with infection
control in the LTCF (Category II).
8
The ICP should communicate with relevant facility committees and personnel within
the facility, ICPs from transferring facilities, and public health authorities to
ensure appropriate isolation and collection of surveillance information (Category
II).
9
No recommendation on number of ICPs per 100 LTCF beds.
D. Surveillance
1
The LTCF should have a system for ongoing collection of data on infections in the
institution (Category IC).
2
A documented surveillance procedure should be used, including written definitions
of infections (Category IB).
Comment: Concurrent surveillance is preferable to retrospective surveillance. The
frequency of surveillance for HAIs in the LTCF should be based on factors such as
acuity level of the resident population. Surveillance at least once a week generally
is needed to collect timely data. Surveillance data should be collected from communication
with staff; this may be during walking rounds in the LTCF. Medical progress notes
in the chart, laboratory or radiology reports, nursing notes, treatment records, medication
records, physical assessments, environmental observations, and follow-up information
from transfers to acute care hospitals provide clues to the presence of infections.
3
The ICP should review surveillance data frequently and recommend infection control
measures, as appropriate, in response to identified problems (Category IB).
Comment: Analysis of surveillance data should include at least the following elements
on each infection to detect clusters and trends: resident identifier, type of infection,
date of onset, location in the facility, and appropriate laboratory information.
4
Infection rates should be calculated periodically, recorded, analyzed, and reported
to the administration and the infection control oversight committee (Category IB).
Comment: Infection rates usually are calculated monthly, quarterly, and annually.
HAI rates are calculated preferably as infections per 1000 resident-days. A standard
infection report form facilitates reporting of surveillance information. Tables, graphs,
and charts may be used and facilitate education of personnel.
5
Surveillance data should be used for planning infection control efforts, detecting
epidemics, directing continuing education, and identifying individual resident problems
for intervention (Category IB).
Comment: In addition to collection of baseline infection rates, the ICP should perform
problem-focused studies. Examples of special studies are evaluation of UTIs in catheterized
residents, a study of the occurrence of influenza in vaccinated versus unvaccinated
residents, or the prevalence of pressure ulcers in bed-bound residents.
6
In addition to the above outcome measures, surveillance should also include analysis
of process measures relevant to infection control (Category II).
Comment: Examples include monitoring hand hygiene compliance, observation of aseptic
technique, and measuring HCW influenza vaccination rates.
E. Outbreak control
1
Surveillance data should be used to detect and prevent outbreaks in the LTCF (Category
IB/IC).
Comment: The occurrence of even a single verified case of a highly transmissible disease
(such as infectious TB, influenza, scabies, Salmonella, and norovirus) in the LTCF
should prompt notification of appropriate individuals (such as the medical director
or administrator), consideration of an outbreak, and institution of control measures.
After the institution of isolation precautions, assessment of exposed residents and
personnel should be made in a timely fashion to detect other cases.
2
The facility should define authority for intervention during an outbreak (Category
IB).
Comment: The LTCF should have a preexisting protocol for dealing with infectious disease
epidemics, including the authority to relocate residents, confine residents to their
rooms, restrict visitors, obtain cultures, isolate, and administer relevant prophylaxis
or treatment (such as antivirals during an influenza outbreak).
3
In order to facilitate response to an outbreak, consent for appropriate diagnostic
or therapeutic measures should be obtained from the resident or medical decision maker
and the resident's primary physician on admission to the facility (Category II).
4
Obtaining cultures of the environment or from asymptomatic personnel is not recommended
except as targeted by an epidemiologic investigation (Category II).
5
A TB control program should focus on detection of active cases in residents and staff
and isolation or transfer of residents with known or suspected pulmonary TB disease
(Category IC).
Comment: TB control programs are mandated by OSHA. A case of TB in residents or staff
that was or may have been acquired in the facility should lead to clinical evaluation
and TB testing of residents and employees.
F. The facility
1
Hand hygiene facilities and supplies should be available and conveniently located
for residents and staff (Category IA).
2
Clean and soiled utility areas should be functionally separate and clearly designated
(Category IC).
3
Appropriate ventilation and air filtration should be addressed by the LTCF (Category
IC).
Comment: If the LTCF provides care for residents or accepts residents with a diagnosis
of active TB, the airborne infection isolation (AII) requirement should be met. If
these requirements cannot be met, a system for transfer of cases to an appropriate
institution that provides AII should be part of the overall infection control plan.
4
Housekeeping in the facility should be performed on a routine and consistent basis
to provide for a safe and sanitary environment (Category IC).
Comment: Cleaning schedules should be kept for all areas in the LTCF. Cleaning products
should be approved and labeled appropriately; manufacturer's (or other authoritative)
recommendations for use and dilution should be followed.
5
Measures should be instituted to correct unsafe and unsanitary practices (Category
II).
Comment: Environmental cleanliness may be monitored by walking rounds with a checklist
for each area of the LTCF. Nursing interventions may be monitored by direct observation
during such rounds.
6
Areas in the LTCF with unique infection control concerns (eg, laundry, kitchen, rehabilitation)
should have the appropriate policies and procedures developed (Category II).
Comment: Laundry policies and procedures should address the following: proper bagging
of linen at the site of use, transporting linen in appropriate carts, cleaning of
the carts on a regular basis, separation of clean and soiled linen, washing temperatures
or use of an appropriate chemical mix for low-temperature washing, covering of clean
linen, protection of personnel handling soiled laundry, and hand hygiene after contact
with soiled linen. Adequate supplies of clean linen should be available. Laundry regulations
should be addressed if the facility does its own laundry. Dietetic service area policies
and procedures should address the following: handling of uncooked foods, cooking of
food, cleaning of food preparation areas, food storage, cooking and refrigeration
temperatures, cleaning of ice machines, hand hygiene indications, and employee health.
Food and drink should be limited to specific areas. Policies and procedures covering
infection control aspects of physical therapy (including cleaning of hydrotherapy
tanks) should be developed. It should include cleaning and disinfection of hydrotherapy
equipment, hand hygiene indications, and cleaning of exercise equipment. If pets are
allowed, the LTCF should have a policy defining access, containment, cleanliness,
and vaccination of pets.
7
Policies and procedures for disposal of infectious medical waste (including waste
categorization, packaging, storage, collection, transport, and disposal) should be
developed in accordance with federal, state, and local regulations (Category IC).
Comment: Examples of specific issues include types of waste disposal bags, cleaning
of waste transportation carts, and types of waste storage containers. Policies for
sharps disposal should be developed.
G. Isolation and precautions
1
Isolation and precautions policies and procedures should be developed, evaluated,
and updated in accordance with most recent CDC/HICPAC guidance (Category IC).
2
Regular education programs should be developed to reinforce understanding and compliance
(Category IC).
3
Compliance with these infection control practices (eg, hand hygiene, isolation) should
be monitored (Category IC).
4
Any isolation and precautions system used should include implementation of Standard
Precautions for all residents (eg, wearing of gloves, masks, eye protection, and gowns
when contamination or splashing with blood or body fluids is likely) (Category IC).
5
Any isolation and precautions system should include the implementation of transmission-based
precautions (Contact Precautions, Droplet Precautions, or Airborne Precautions) in
accordance with current CDC/HICPAC guidance (Category IB/IC).
6
The LTCF should have a policy dealing with MDROs (such as MRSA or VRE) that is compatible
with current national standards (such as the HICPAC isolation and MDRO guidelines)
and appropriate to the LTCF setting (Category IB).
Comment: This policy should deal with issues such as acceptance of colonized or infected
patients into the facility, inquiring about colonization of admissions with MDROs,
and isolation of residents with MDROs. Denial of admission to the LTCF solely on the
basis of colonization or infection with a resistant organism is not appropriate. HICPAC
recommends intensification of containment measures for MDROs if ongoing transmission
is occurring.
7
The individual resident's clinical situation should be considered when deciding whether
to implement or modify the use of Contact Precautions in addition to Standard Precautions
if colonized or infected with a MDRO (Category IB/IC).
Comment. Routine glove use is an example of a form of modified Contact Precautions,
but it has not been validated in the LTCF setting.
8
A program of safe work practices to prevent HCW exposure should be developed in accordance
with CDC/HICPAC and OSHA guidance. Used needles and syringes should not be manually
recapped, broken, or bent. Self-capping needles should be used. They should be disposed
of, with all sharps, in a puncture-resistant, leak-proof container (Category IC).
9
Gloves are indicated for contact with blood or body fluids, contaminated items, mucous
membranes, or nonintact skin (Category IC).
10
Policies should be developed to deal with spills and personnel exposure to blood or
body fluids. Employees should know how to respond to an exposure (eg, immediately
washing the skin in the event of a blood exposure). Postexposure prophylaxis should
be readily available (Category IC).
11
Residents with suspected TB should be placed in a negative-pressure room or transferred
to a facility with such a room (Category IC).
H. Asepsis and hand hygiene
1
Routine hand hygiene should be encouraged. Hands should be washed after any patient
contact but especially after contact with body fluids, after removing gloves, when
soiled, and when otherwise indicated (Category IA). Unless hands are visibly soiled,
use of alcohol-based hand gels is encouraged (Category IA/IC).
2
A hand hygiene policy and procedure should be developed by the LTCF in accordance
with current CDC/HICPAC guidance with a program of ongoing hand hygiene education
(Category IB/IC).
3
Hand hygiene compliance should be monitored (Category IC).
4
Policies and procedures for disinfection and sterilization should be developed (Category
IB).
Comment: These policies and procedures should address issues such as sterile supplies,
reuse of disposable items, disinfection of equipment (such as thermometers), and cleaning
of noncritical items. All items, other than disposables, should be cleaned, disinfected,
or sterilized, following published guidelines and manufacturers' recommendations.
The ICP should identify those resident care procedures that require aseptic technique.
I. Resident care
1
Resident rooms should have an accessible sink, with soap, water, towels, and toilet
facilities (Category II).
Comment: Provision should be made for maintaining adequate resident personal hygiene
and for instructing residents in hygiene and hand hygiene as appropriate to their
functional status.
2
A resident skin care program should be developed to maintain the skin as a barrier
to infection (Category II).
Comment: Resident skin care should include the following: routine frequent turning
for those unable to do so themselves, keeping the residents clean and dry, inspecting
all residents' skin on a routine basis, ensuring appropriate nutrition, treating pressure
ulcers, and providing prompt care for any other breaks in skin integrity. Turning
schedules and pressure ulcer assessment forms may be useful.
3
A program to prevent UTIs should be developed, including the following:
•
Routine urinalysis or urine culture to screen for bacteriuria or pyuria is not recommended
(Category IA).
•
Residents with impaired bladder emptying managed with intermittent catheterization
should be managed with a clean technique (Category IA).
○ Policies for catheter use should address catheter insertion, closed drainage systems,
maintenance of urinary flow, and indications for changing the catheter (Category IB).
○ Irrigation of indwelling catheters with saline or antiseptics is not routinely recommended
(Category IB).
•
If leg bags are used, the LTCF should develop policies and procedures for aseptic
connection, cleaning, and storage of leg bags (Category II).
•
Adequate hydration should be maintained (Category II).
Comment: Men with incontinence should have voiding managed by a condom catheter rather
than indwelling catheter, where possible. Residents with chronic indwelling catheters
should have the catheter replaced and a specimen collected immediately prior to initiating
antimicrobial therapy for symptomatic infection.
4
A program to minimize the risk of pneumonia in the LTCF should address the following:
reducing the potential for aspiration, minimizing atelectasis, and caring for respiratory
therapy equipment (Category II).
Comment: Pneumonia prevention guidelines are available, and many of the suggested
measures are applicable to the LTCF.
5
Policies and procedures should be developed for prevention of infections associated
with nasogastric and gastrostomy feeding tubes, including the following: preparation,
storage, refrigeration, and administration of feeding solutions and care of percutaneous
feeding tube skin sites (Category II).
6
Policies and procedures should be developed for prevention of IV infections, including
central lines, if these devices are used (Category IB).
Comment: Policies should address indications for IV therapy, the type of dressing
used to cover the IV exit site, cannula insertion, site maintenance, and changing
fluids or tubing.
J. Resident health program
1
A resident health program should be implemented (Category II).
•
There should be explicit and accessible documentation of program components in the
resident record (Category II).
2
At admission, each resident should have a complete history (including important past
and present infectious diseases), immunization status evaluation, and recent physical
examination (Category II).
3
All newly admitted residents should receive TB screening unless a physician's statement
is obtained that the resident had a past positive TST (Category IA/IC).
Comment: A 2-step booster TST is often recommended in this setting.
4
When new or active TB is suggested by a positive skin-test result, or symptoms are
consistent with active TB, a chest radiograph and medical evaluation should be obtained
(Category II).
5
Follow-up TST for TB should be performed periodically or after discovery of a new
case of TB in a resident or staff member (Category IB). No recommendation on frequency
of routine follow-up TSTs for residents.
6
Each resident should receive current vaccinations for tetanus, diphtheria, influenza,
pertussis, pneumococcal pneumonia, and any other vaccines recommended by the ACIP
(Category IB/IC).
7
Each resident should receive the influenza vaccine annually in the fall, unless medically
contraindicated (Category IC).
Comment: Facilities should obtain resident consent at admission for yearly influenza
vaccination and use standing orders for yearly influenza vaccination.
8
Policies and procedures addressing visitors should be developed to limit introduction
of community infections (such as influenza) into the LTCF (Category II).
K. Employee health program
1
All new employees should have a baseline health assessment, including immunization
status and history of relevant past or present infectious diseases (Category 1B/IC).
Comment: The past history of infectious diseases should address contagious diseases
such as chickenpox, measles, hepatitis, furunculosis, and bacterial diarrhea. Screening
cultures of new employees are rarely indicated.
2
All new employees should receive TST unless there is written documentation that the
employee had a positive reaction to a tuberculin test. When new or active TB is suggested
by a positive TST result or by symptoms, a chest radiograph and medical evaluation
should be obtained (Category 1A/IC).
Comment: A 2-step booster TST technique is recommended when indicated. Only employees
who have active pulmonary TB should be restricted from work.
3
Follow-up skin testing of staff who are TST negative should be performed periodically
based on the facility's annual risk assessment or after discovery of a new case of
TB in a resident or staff member (Category 1A/IC).
Comment: The intradermal Mantoux method or licensed blood test should be used. The
frequency of testing depends on the regional prevalence of TB; the facility's annual
risk assessment; and federal, state, or local regulations.
4
All employees should have current immunizations as recommended for HCWs by the Advisory
Committee on Immunization Practices (ACIP), with documentation in the employee record
(Category 1A/IC).
5
Employees with blood or body fluid contact should be offered HBV immunization within
10 working days of hire and after training has been completed (Category 1C).
Comment: Refusal of this vaccine should be documented, using the OSHA-required Declination
Statement for Hepatitis B vaccine.
6
Employees should be offered the influenza vaccine annually (Category 1A/1C).
Comment: A vaccine declination statement may be signed by each employee who declines
influenza vaccination.
7
Each employee should be taught basic use of personal protective equipment and hand
hygiene and to consider blood and all body fluids as potentially infectious (Category
1C).
8
Employees with signs or symptoms of communicable diseases (eg, cough, rash, diarrhea)
should not have contact with the residents or their food (Category 1B).
9
All employees should be educated to report any significant infectious illnesses to
their supervisor and the staff member responsible for employee health (Category 1B).
Comment: Each employee record should include factors affecting immune status (such
as steroid therapy, diabetes, HIV infection), history of communicable diseases, illnesses,
and incidents such as exposures to contagious diseases, needlesticks, injuries, and
accidents.
10
The LTCF should develop protocols for managing employee illnesses and exposures (such
as bloodborne pathogens like HIV and hepatitis B and C, as well as TB, scabies, or
gastroenteritis) (Category 1B/IC).
Comment: An employee absentee policy that discourages the employee from working while
ill should be developed.
L. Education
1
Infection control education should be provided at the initiation of employment and
regularly thereafter. Training should include all staff, especially those providing
direct resident care (Category IC).
2
All programs should be documented with the date, topic, names of attendees, and evaluations
(Category IC).
Comment: Program topics should be timely and relevant to infection prevention and
control. Basic hygiene, hand hygiene, respiratory etiquette, transmission of infectious
diseases, occupational health, prevention of TB and bloodborne pathogens, Standard
and Transmission-based Precautions, infection control standards, and the susceptibility
of residents to infectious diseases are topics that should be included. The ICP may
recommend topics. Surveillance data are of interest to staff and may be included as
appropriate. The educators should evaluate the educational program and outcomes and
use that information to modify future programs.
M. Policies and procedures
1
Infection control policies and procedures dealing with relevant aspects of infection
control such as hand hygiene, disinfection, and isolation precautions should be in
place and compatible with current regulations and infection control knowledge (Category
IC).
2
Infection control policies and procedures should be approved, reviewed, and revised
on a regular basis (Category IC).
Comment: The ICP should assist in the development and updating of infection-related
policies and procedures.
3
Employees should be made aware of infection control policies and procedures (Category
IC).
Comment: The ICP should develop a system for monitoring staff compliance with infection
control policies and procedures.
N. Antibiotic stewardship
1
Infection control programs in LTCFs should be encouraged to include a component of
antimicrobial stewardship (Category IB).
Comment: The LTCF should encourage judicious use of antimicrobials with guidelines
based in part on local susceptibility patterns. Antibiotic utilization and appropriateness
may be monitored, and these data used for interventions (eg, education, antibiotic
restrictions).
2
The ICP should monitor antibiotic susceptibility results from cultures to detect clinically
significant antibiotic-resistant bacteria (such as MRSA or VRE) in the institution.
Changes in antibiotic-susceptibility trends should be communicated to appropriate
individuals and committees (Category IB).
O. Miscellaneous aspects
1
There should be a system for reporting notifiable diseases to proper public health
officials (Category 1C).
2
The infection control program should collaborate with the performance improvement
(PI) program, if a formal program exists (Category II).
Comment: Infection control is an important component of PI, and the epidemiological
techniques used in infection control will assist the PI program.
3
The ICP should be involved with the review and selection of new products that have
infection control implications (Category II).
4
The ICP should be involved with LTCF influenza pandemic preparedness planning (Category
II).
5
Infection control activities should address relevant resident safety issues (Category
II).
P. Regulations
1
The infection control program must be in compliance with federal, state, and local
regulations (Category IC).
2
The infection control program should reflect national, evidence-based standards of
practice for infection prevention and control (Category IC).