Infection Prevention in Long-Term Care Facilities: A Significant Cultural Transformation is Underway
Each year, more than 4 million U.S. patients are admitted to or reside in long-term care (LTC) facilities with an estimated 1-3 million acquiring serious infections and approximately 380,000 of those infections resulting in death.1 The common infection types include urinary tract, diarrheal diseases, bacterial and viral respiratory tract and infections due to multidrug-resistant organisms (MDRO) such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile (C. difficile) and Candida auris (C. auris), an emerging fungal pathogen. These infections are associated with readmission to acute care hospitals and cost billions in additional health care costs per year. The frequency of inter-facility transfers, high acuity and use of invasive devices (e.g. urinary catheters and central venous catheters), as well as the overutilization of antibiotics has resulted in an extremely high MDRO prevalence in this population.
A public health collaborative conducted in Southern California found an MDRO prevalence of 65% among the screened nursing home residents with MRSA identified as the most common MDRO and only 18% of these residents were known to be colonized.2 This high rate of MDRO colonization leads to contamination of the environment, reusable medical equipment and the hands of both health care personnel (HCP) and residents. Residents with MDROs may remain colonized for months and in the absence of infection, are not placed on Contact Isolation (CI) precautions, which requires gowning and gloving for direct care. The use of standard precautions, which lack concrete guidelines regarding when to wear gowns and gloves, are utilized in order to balance resident quality of life over resident safety and to follow guidance from the Centers for Medicare and Medicaid Services (CMS) which dictates that transmission-based precautions should be as least restrictive as possible and used for the least amount of time.3 However, studies conducted by Roghmann and colleagues4 and Phan et al5 have found that gloves and gowns are substantially contaminated with MRSA during high-risk care activities of daily living and when Healthcare Personnel (HCP) are caring for patients with viral respiratory illness, respectively. These findings suggest that the lack of HCP gown and glove use in the LTC setting, along with hand hygiene compliance rates reported to be <60%6, represent significant infection prevention gaps that contribute to transmission of MDROs and health care-associated infections (HAIs).
In response to the clear need for improvement of fundamental infection prevention and antimicrobial stewardship practices, CMS issued a final rule in October, 2016 revising the requirements that LTC facilities must meet to participate in the Medicare and Medicaid programs.7 This final rule specifies that LTC facilities must develop an Infection Prevention and Control (IPC) program reporting through the quality assessment and performance improvement (QAPI) program, an Antibiotic Stewardship Program (ASP) and designate at least one Infection Preventionist (IP) who is qualified through education, training, experience, or certification. Facilities were allowed a phase-in period which ends on November 28, 2019. To assist facilities with the CMS educational requirements for an IP, the Centers for Disease Control (CDC) in collaboration with CMS released a free LTC infection prevention training course and the American Health Care Association developed an online, self-study program.
In addition to these regulations, IPs in LTC received an interim guidance document from the CDC entitled Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs) which specifies the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to HCP hands and clothing.8 The new precautions are called Enhanced Barrier Precautions and the targeted MDROs are pan-resistant organisms, carbapenemase-producing Enterobacteriaceae, Pseudomonas spp., and Acinetobacter baumannii, and C. auris. The document emphasizes that focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization for prolonged periods of time.
Compliance with the CMS requirements as well as Enhanced Barrier Precautions will be challenging for LTC facilities and will require a change in culture to embrace and sustain new practices. Hand hygiene must be improved for both HCP and residents and can be achieved through product availability, education and compliance monitoring. Promotion of hand hygiene to residents prior to mealtime, after using the bathroom and before joining communal activities should be part of the IPC program. The cleaning of reusable medical equipment can be promoted through the availability of disinfectant wipes in safe, but convenient, locations throughout the facility accompanied by education regarding manufacturer’s instructions for use. The appropriate use of PPE, meticulous hand hygiene practice and thorough cleaning of the environment and reusable medical equipment will substantially contribute to the reduction of MDROs and HAI transmission in the LTC setting.
1 Centers for Disease Control website: accessed on November 11, 2019 https://www.cdc.gov/longtermcare/index.html.
2 McKinnell JA, Singh RD, Miller LG, et al. The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California. Clin Inf Disease 2019;69(9):1566-1573. doi: 10.1093/cid/ciz119.
3 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17. State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 pages]. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
4 Roghmann MC, Johnson JK, Sorkin JD, et al. Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to Healthcare Worker Gowns and Gloves During Care of Nursing Home Residents. Infect Control Hosp. Epidemiol 2015;36(9):1050–1057.
5 Phan LT, Sweeney D, Maita D, et al. Respiratory viruses on personal protective equipment and bodies of healthcare workers. Infect Control Hosp. Epidemiol 2019;1-5.
6 Schweon S, Edmonds SL, Kirk J, et al. Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility. Am J Infect Control 2013;41:39-44.
7 CMS Final Rule: accessed on November 11, 2019. https://www.govinfo.gov/content/pkg/FR-2016-10-04/pdf/2016-23503.pdf
8 Centers for Disease Control: Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs): accessed November 11, 2019. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html