With the focus on infection and process surveillance greater now than ever before, facilities are also expected to monitor and enforce hand hygiene compliance and other infection prevention activities. To boost your success, consider appointing an infection preventionist to coordinate infection prevention and control programs, assess the infection risks of the facility and resident population, perform surveillance, provide education and ensure compliance with evidence-based prevention practices guidelines.

Infection Surveillance

Infection surveillance is "the ongoing, systematic collection, analysis, interpretation and dissemination of data to identify infections and infection risks, to try to reduce morbidity and mortality and to improve resident health status."¹You need to use ongoing monitoring and communication with caregivers to gather data and enter it into standardized forms used to track and trend rates over time. Some data mining software is available to facilities with electronic documentation, but most facilities are performing this surveillance by hand.

Essential components of a thorough infection surveillance process include identifying specific infections through the use of standardized definitions and pinpointing the population at risk either by resident days or device days, such as the number of residents with a urinary catheter or PICC line.

In 1991, Allison McGeer and colleagues developed a set of definitions for infection surveillance in long-term care facilities. Since that time, many facilities have adopted the McGeer definitions, but they haven't been validated and are up for review in the coming year.

Other facilities adhere to the National Healthcare Safety Network surveillance definitions commonly used in the acute care setting. These take into account additional lab and radiologic findings. Infection rates are calculated by dividing the number of infections by the population at risk, and multiplying this by a constant to achieve a rate.

For example, if two patients with Foley catheters meet the definition of a urinary tract infection during the month, and there were 240 catheter days, the calculation would be: 2 UTIs / 240 catheter days = .0083 X 1,000 (constant) = 8.3 catheter-associated UTIs per 1,000 catheter days.

To monitor infection rates as an outcome of prevention activities, you must choose one set of definitions and use them consistently. Once you establish a baseline, data should be analyzed, trended and shared with staff so the appropriate prevention and control measures can be implemented and adjusted according to outcomes.

Process Surveillance

Resident care practices aimed at reducing the risk of infection include hand hygiene, isolation or transmission-based precautions, and the use of gloves and other personal protective equipment. Process surveillance is generally accomplished through direct observation and can be extremely labor intensive, but there are tools available to simplify the process.

For example, internal audit tools may include observations of multiple activities, and can capture data on an electronic spreadsheet for trending over time. Staff and resident surveys may be used to supplement process surveillance, and might be useful in measuring compliance, enhancing staff awareness and improving resident satisfaction. Once this is accomplished, compliance data should be used to guide corrective actions and educational efforts.

Hand Hygiene Compliance

In terms of hand hygiene compliance, CMS' revised State Operations Manual mentions adherence to standards of accepted professional practice, specifically the 2002 CDC Hand Hygiene in Healthcare Settings.

Health care workers are expected to decontaminate hands, either with an alcohol-based handrub (ABHR) or with antimicrobial soap and water, both before and after direct contact with a resident. Hands must be washed with soap and water when visibly soiled, before eating, after using the restroom and after potential contact with spores. In all other situations, hands should be decontaminated with an ABHR.

Many facilities provide ABHRs to staff and residents, but hand hygiene compliance is often suboptimal. Adding to this challenge is the fact that subtle inconsistencies exist between CDC guidelines and the CMS interpretive guidance.

For example, CMS requires the use of soap and water after contact with residents with infectious diarrhea, after performing personal hygiene, and after eating and before assisting with resident toileting. Additionally, hands must be washed or sanitized when beginning and completing duty, regardless of timing with resident care activities, whereas the CDC guidelines spell out the indications before and after performing specific procedures.

Practical Applications

Balancing infection prevention activities with the pursuit of a clean home-like environment can be challenging, especially in isolated settings. The CMS State Operations Manual advocates the use of isolation signs and convenient staff access to protective equipment, and some facilities have come up with clever and discreet ways to facilitate infection prevention and control.

For example, isolation signs may be color-coded and display softer language, such as "Welcome! Please check with the nurse before entering." In addition, supplies may be stored in designated cabinetry or drawers instead of traditional plastic wall boxes.

IC and Dining

Infection control practices are also imperative in group activities, such as dining. Here are a few strategies to enhance the dining experience while maintaining necessary infection control measures:

• If food is served buffet-style, provide serving utensils that prevent direct contact with food. Avoid short serving handles, which may result in hand contamination.

• Consider using baskets of condiment packets instead of shared refillable bottles.

• Glove use during food prep is non-negotiable, but the need for gloves in the dining room may be minimized by coordinating food prep and dining activities. Whenever possible, perform food prep requiring gloves in the kitchen and use utensils to serve food in the dining room.

• Never handle food with bare hands. Unless gloves are used, tasks like preparing condiments and assembling sandwiches must be done using utensils or another barrier, such as deli paper.

• Resident hand hygiene is also important. If soap and water aren't available, offer hand sanitizer or sanitizing hand wipes to encourage cleaning hands before dining.

• When assisting residents with meals, the use of hand sanitizer by health care workers is safe and acceptable. Installing dispensers in convenient locations in the dining room may also enhance resident hand hygiene compliance.

• Ensure that place mats, table linens and furniture are cleaned routinely.

Providing a clean, home-like environment will improve safety outcomes and provide a higher quality of life to residents.

Reference

1. Center for Medicare & Medicaid Services. State Operations Manual. December 2, 2009: p. 563.

Trina Zabarsky is a long-term care infection preventionist at the Cleveland VA Medical Center, Brecksville, Ohio.