Assurance that the facility has an infection control program which is effective for investigating and preventing infections.

A. Guidelines:

1. Monitor and investigate causes of infection and manner of spread.

As you can see from the above graph, urinary isolates were mainly from enteric (intestinal) organisms. MONITOR: There was a continuous rise in each quarter for 2000. This could have been due to a variety of reasons, one of which is endogenous contamination. INVESTIGATE: Since Escherichia coli, Enterococcus faecalis and Proteus mirabilis are commonly found in stools, perineal contamination is a common source for these organisms to cause urinary tract infections. IDENTIFY CAUSE: Personnel who use gloves and do not change them between sites can transfer organisms mechanically. INFORMATION: The nursing staff should be able to develop graphic displays over quarters to see what organisms are causing infections and take action to reduce or eliminate. ACTION: Reference laboratories should be able to develop epidemiology reports with annual graphics to help the nursing and medical staff investigate the causes of infection and manner of spread.

2. Maintain a separate record on infection that identifies each resident with an infection, states the date of infection, the causative agent, the origin or site of infection and describes what precautionary measures were taken to prevent the spread of infection within the facility. The following Table may be used:

As you can see by the above table, a record can be obtain on the identification of each resident with an infection, the date of infection, the causative agent, the origin and site of infection and describing what precautionary measures were taken to prevent the spread of infection within the facility.

This table can be made easier if the facility can obtain the following information from their laboratory.

1. Listing of all common organisms isolated over the last two years. If this can be obtained then the following can help the facility in completing the form.

Organisms

1. Acinetobacter sp.

2. Bacillus sp.

3. Citrobacter diversus

4. Citrobacter freundii

5. Campylobacter sp., etc.

In the section marked organisms, all the staff member has to do is write the number into the blank. On the back of this form the facility can place the listing of the organisms. This makes it a lot easier for the staff that is not familiar with the spelling of the organisms.

2. Listing of all the antibiotics in the same manner as the organisms. Only a number will be placed in the form. For example:

Antibiotics

1. Ampicillin

2. Amikacin

3. Augmentin

4. Bactrim, etc.

This will make it easier for the staff member that is not familiar with the spelling of the antibiotics.

3. Specimen type can also be written as the organisms and antibiotics above. For example:

Specimens

1. urine - CC

2. urine - CATH

3. urine - INTERMITTANT

4. lower respiratory

5. upper respiratory

6. wounds (place anatomical area) and manner of collection

7. stool

8. blood

9. anterior nares (swab)

10. perineal (swab)

11. GT site

12. ______________other

Have your reference laboratory help you in designing a form which is compatible with your facility. Make the form as conclusive as possible so that the staff member assigned to the infection control program does not have to keep going back to the charts for examination.

3. System must enable the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

The person who has been assigned to obtain and analyze data should do the following:

On a daily basis, place all microbiology reports in folders according to specimens. For example, all urines, wounds, sputa, etc. for the month of X are placed in folders as they come in on a daily (or weekly) basis. Examine the reports for obvious organisms and perform a quick tabulation). For example:

As you can see from this table, there is an apparent problem with methicillin-resistant Staphylococcus aureus in this facility (more than 3 infections in a prescribed time). The person who is doing the analyzing must be able to differentiate between colonization and infection. With ready access to laboratory data, the facility can determine clusters, changes in prevalent organisms or increases in rates of infection in a timely manner. In service education on basic hygienic behavior among the staff members and residents can be quickly reestablished. Charts can be drawn over a period of months to see how well the facility is doing in controlling the problem and can be used as educational tools for both nursing and medical staff. For example:

As you can see by the Figure above, the 3rd quarter demonstrated the highest number of isolates. Nursing homes are not going to totally eliminate colonized or infected residents with MRSA. But certainly they can control its spread through recognition, education and surveillance. Surveillance data should be routinely reviewed and recommendations made for the prevention and control of additional cases.

An epidemiology report generated on a quarterly basis by a reference laboratory can be reviewed by the infection control committee or quality review committee to determine if problems are developing. Discussions can center around some of the data accumulated.

4. The surveillance data above can be routinely reviewed and recommendations made for the prevention and control of additional cases. For example a graph could be presented to the infection control committee concerning the increase of urinary tract infections within the facility over a period of months. For example:

As you can see by the above figure, this facility has problems with enteric isolates causing urinary tract infections. An examination of the above table where the residents are listed, can determine which areas of the facility are the most problematic. A graph can be displayed to indicate areas where the facility is having the highest infection rate. For example:

The above figure indicates that Wing A and D had the highest incidence of urinary tract infections. This could be due to many reasons. For example, the types of residents in Wing A and D could be more acutely ill which could predispose them to urinary tract infections (eg. incontinence, immobility, altered mental status, immunocompromised), or there could have been more staff changes within these wings that could have accounted for inconsistent care, or many of the residents within these wings had prior hospitalization and had foley catheters for a period of time. For what ever reason, the infection control committee would have sufficient data to tabulate and analyze the problem and make recommendations to the medical and nursing staff.

5. The written infection control policy should be reviewed annually by the infection control committee or designated personnel with qualifications. An active infection control should have written protocols/policies.

In order to have a system for review of all policies, the following table should be developed:

Infection Control Policy and Procedure Manual - calendar (approved by QI)

1. Handwashing
2. Employee health including work restriction
3. Visitor control
4. Prevention of intravascular infections
5. Prevention of urinary tract infections (bladder incontinance)
6. Prevention of decubiti and/or infections
7. Tracheotomy care
8. Bowel incontinence
9. Immunosuppressive residents
10. Stoma care
11. Surveillance techniques
12. Specimen obtainment and transport
13. Mechanisms of reporting communicable diseases to the local health department
14. Specific isolation techniques beyond standard precautions (Universal precautions)
15. List of all educational programs for the staff during ____year (including orientation checklists)
16. Definitions of infections
17. Risk assessments of occurrence of communicable diseases

18. TB exposure control plan which includes residents with signs and symptoms of tuberculosis and a referral protocol

19. Measures for the prevention of influenza

20. Measures for the prevention of MRSA

21. Measures for the prevention of VRE

22. Measures for the prevention of hepatitis A and B

23. Measures for the prevention of scabies

24. Housekeeping infection control practices (including sanitation of tubs, whirlpools and common use equipment)

25. Laundry infection control practices which include handling of disinfectants

26. Dietary infection control practices

27. Authority in writing for indications and procedures for obtaining and acting upon microbiological cultures and for isolating residents

1. Observe sanitation of tubs, showers, multiple residents' whirlpool and care equipment

2. Identify all residents in the sample who are currently on antibiotic therapy and verify that these residents are reported on the facility's infection control logs/record to ensure that infections are being identified timely and that these residents are being adequately monitored for infections. Work with your pharmacist so that they can supply you with a weekly report on whose is on antibiotics. This is important for a variety of reasons. For example:

1. The listing could contain common antibiotics being used;

2. Residents who are on a prophylactic regimen which could increase antibiotic resistance;

3. Indiscriminate use of costly antibiotics;

4. Residents on antibiotics that are not cultured;

5. Wrong antibiotic regimens being used on disease-producing organisms;

6. Antibiotics being used on colonized residents suspected of having infections.

The following table could be used to determine the above:

3. Review policies related to infection control if observation, record review, or staff interview indicate a problem with infection control.

4. Observe direct care staff routinely washing their hands according to facility written protocols.

5. Observe whether staff, including direct care nurses, housekeeping, kitchen staff, etc. use gloves as required by facility policy.

The use of performance indicators where evidence of some kind is used to indicate how well or how infrequent a procedure is being performed can be a tool of surveillance on infection control procedures. For example the number of glove boxes assigned may serve as an indicator. For example the following graph can indicate the use of gloves over a period of time in relation to service within the facility:

The above graph shows the number of glove boxes assigned. In order to determine if the gloves were used, one would have to perform a study on the number of used gloves visualized. This would probably be unrewarding to the person assigned this duty.

6. Determine if there is consistent use of aseptic techniques for dressing changes.

Direct observation of staff on the job provides the most and efficient information on the skill and quality performance of personnel. This is the most time consuming measure of behavior which requires a clear definition of target behavior, surveyor's training, a statistical sampling of staff and specific time periods to observe in order to produce valid data. A checklist should be developed in accordance with the policy of the facility. A summary report would have to be developed. Time, duration and frequency of behavior occurrence and rates are most clearly understood when graphed. For example:

As you can see by the above graph, the compliance of handwashing increased when the staff recognized that they were being monitored.

I think that you now have a good idea on how to comply with infection control practices. The most important factor is to develop a good infection control manual so that it can be used for instruction and reference. If you have any questions, please call me at my home office.