This manuscript is intended to help long-term health care facilities in developing procedures and in-service educational seminars for infection control programs. This manuscript is by no means a complete format for infection control practices nor is it intended to be used as a single manuscript for presentation to Licensure and Regulation or a similar regulating body as the facilities only written document for infection control. It is to be used as a guide to help in the development of the facilities final manual for infection control.

Many of the residents in long-term care are at increased risk of developing infections because of underlying intrinsic problems which may alter many of the normal defense mechanisms of the human body. In addition, the closed environment of facilities provide a greater opportunity for the transmission of pathogenic and opportunistic organisms.

Age has always been a major risk for infection. Increased susceptibility of older individuals to infectious diseases has been attributed to the interplay of many factors such as the decline of the immune system (decrease in cellular immunity), chronic underlying diseases (diabetes), nutrition, physiologic changes, and alteration in the mental status.

Little is really known about the true infection rates of long-term care facilities. They certainly can not be compared with hospital rates because of different patient cliental and the environmental conditions are certainly not the same. As we progress in the development of surveillance programs for long-term care, general rates and conditions for infections will be more widely known. However, there are some common infections that seem to be intrinsic to nursing homes. These are urinary tract infections (often caused by the resident's own organisms), skin lesions often caused by breakdown (decubiti), pneumonia (aspiration and viral), conjunctivitis and gastrointestinal (viral and bacterial).

The surveillance officer for a long-term care facilities, often referred to as an infection control practitioner (ICP) must understand the common sites of infections, underlying conditions, environmental factors, types of organisms that commonly cause disease, how are they transferred, and be able to interpret laboratory data in order to formulate policies and procedures for infection control in her or his facility.

In order to develop an effective infection control program for long-term care, we have to begin with either an Infection Control Committee or incorporate within the Quality Assurance Committee a mechanism to determine the cause and prevention of infections.

A functional infection control committee develops the policies and procedures that are needed for each individual facility. This responsibility can not fall on only one person. There should be representatives from each service with the facility. This is made of individuals who are caring, understandable, unselfish and who are willing to spend some time in developing a workable program. Examples of some committee members are:

1. Medical Director (permanent member)
2. Administrative Representative (permanent member)
3. Director of Nursing or a representative from Nursing (permanent member)
4. Infection Control Practitioner (preferably an RN)
5. Microbiologist (from the reference laboratory as a consultant)
6. Supervisor of Housekeeping (ad hoc member)
7. Dietary Supervisor (ad hoc member)
8. Pharmacy representative (ad hoc or permanent member)
9. Maintenance representative (ad hoc member)
10. Physical/Occupational therapist representative (ad hoc member)

The above list is long but as you can see some of the members are ad hoc. Not all the members need to attend each meeting. For example, if the infection control committee needs to talk about antibiotic utilization because of a significant rise in resistant organisms, then the pharmacist can come to the meeting to discuss and evaluate the problem. Try to keep the numbers to a minimum, otherwise it will become to cumbersome and sometimes boring to those who have no background.

The surveillance officer, or the nurse epidemiologist, or the infection control nurse, or the infection control practitioner, or what ever title is acceptable by the facility, has many responsibilities. She or he will be a central figure in the infection control program. Because of this, the appointment of this individual by the administrator is very crucial. This individual should have the following qualifications:

1. Knowledge and experience in clinical nursing
   
   
2. Should know and practice aseptic techniques
   
   
3. Understand methods for preventing cross-infections
   
   
4. Understand the purpose for isolation;
   
   
5. Knows how to communicate well with all disciplines in a tactful and non-threatening behavior;
   
   
6. Working knowledge in basic epidemiology principles;
   
   
7. Familiar with organisms that commonly cause infections in long-term care residents;
   
   
8. Reservoirs of these organisms which include their natural and usual habitats;
   
   
9. Spectrum of disease, particularly with reference to the concepts of colonization, infection, disease, and the carrier state;
   
   
10. Modes of transmission and hosts factors that enhance susceptibility to infection;
    
    
11. Knowledge in microbiological principles that include general   characteristics of the organisms, methods for taking specimens, and able to interpret microbiology laboratory data including antimicrobic susceptibility reports;
    
    
12. Collect, analyze, and report endemic rates of infections;
    
    
13. Develop a surveillance system that can recognize increase rates of infection and clustering;
    
    
14. Understand the principles of cleaning, disinfecting and sterilization.
    

It may be impossible for a nursing home to attract a nurse with all of the above qualifications or even to find one. The alternative is to select a well-respected nurse with as many of the above qualifications as possible. Once the nurse has been selected, she/he should be given formal and/or informal training in order to obtain the skills needed. Your reference laboratory can help in training this individual.

Once the nurse has been appointed to this position, she/he needs to have full support from the administration, medical and nursing staff, and the ancillary staff. Perhaps an introduction of the person at a general meeting with notations of responsibility will help in providing recognition of the individual. Also her/his responsibilities should be clearly defined as well as time allotted for managing the infection control program. The nurse should report to the medical director and the administration. In a nursing home setting, this may be a part-time position. However, under no circumstance should this individual have multitudes of responsibilities such as director or assistant director of nursing, employee health, quality assurance or review person as well as nursing responsibilities.

The infection control nurse can take the responsibility of employee health and assist another person in quality review or assurance.

Major responsibilities of the infection control practitioner are to detect and record facility acquired infections on a systematic and current basis, analyze such infections with the help of the medical director or chairman of the infection control committee (if separate nursing and ancillary staff members, and act as a resource person to all staff members within the health care facility from the infection control committee), the pharmacist and the microbiologist from the reference laboratory, prepare a report for committee review, develop in-service programs for the ancillary staff members within the health care facility. The chairman of the infection control committee (if one exists) should be responsible for the epidemiologic investigation of all significant infections or isolates.

Another important function of the ICP is to understand isolation policies and assist ward personnel in determining where to place infected or colonized residents who require some type of isolation or segregation or co-hort system so there is a lesser chance for cross infection.

The ICP is also responsible for developing or assisting in all infection control policies and procedures in the health care facility whether or not they are involved in direct resident care. She/he may also act a consultant to other committees charged with evaluating procedures and patient care equipment.

The ICP should also assist with employee orientation even though the facility may have a staff development person. Remember that infection control practices begin day one of employment. The ICP is in an excellent position to influence the quality of patient care by making herself/himself available to the medical and nursing staff to help them understand and implement the infection control program.

Responsibility of the chairperson of the infection control committee (if such a committee exists as a single entity)

The medical director or chairman (chairperson) of the infection control committee serves as the nursing home's epidemiologist. The duties ordinarily require a few hours per month depending on the size of the nursing home. Ideally, a physician who is well respected, has interest in the prevention and control of infections, has some training in infectious diseases as it relates to a long term care setting, understands biostatistics and epidemiology would be an excellent candidate for this position. However, it is not always possible to obtain an individual with these qualifications in a nursing home setting. It would be best to obtain an individual who at least has some interest in infection control and is willing to work with the ICP, microbiologist and pharmacist.

The primary responsibility of the chairman (chairperson) of the infection control committee is to advise and direct the infection control practitioner. This individual should supervise the accurate collection and analysis of data on infections and assist in determining whether these infections meet the criteria or guidelines set up by the infection control committee. The chairman (chairperson) should also be responsible for instituting emergency infection control measures when such a problem arises such as an infected methicillin-resistant Staphylococcus aureus (MRSA) or a Vancomycin-resistant Enterococcus sp. (VRE) resident.

How does the chairperson fulfill his/her duties? This individual should be readily accessible to the ICP when questions or problems arise. The ICP and the chairperson should meet to discuss the type of agenda that is going to be presented in the infection control committee meeting so there are no surprises. The time of this meeting can be done at the convenience of both parties. However, it is important that they do meet.

It has been documented that an infection control program, especially one in a nursing home setting will falter if the ICP and the chairperson display no interest. They have to work together and they have to show interest and fulfill their designated responsibilities. It also important that the chairperson of the committee signs and dates the infection control minutes. This will indicate to Licensure and Regulation that at least someone is reading the minutes.

The administrator is really an agent of the board of directors. He/she has the responsibility for seeing that the infection control committee is discharging the responsibility of developing and implementing infection control policies and procedures to their staff. This individual should maintain an organizational framework that translates the judgment of the infection control committee into the policies of the nursing home. With this type of responsibility, the administrator should have some back ground in infection control practices, or at least show some interest on what the committee is trying to accomplish. Until administrators solidly back infection control programs, what has been written so far will never get off the ground.

The infection control committee is composed of multidiscipline individuals whose responsibilities is to deal with current developments and problems. The multi-disciplinary representation is important because infection problems often cross departmental lines and effective decision and effective decision-making requires regular participation of members from most departments. In order to carry out committee's decisions, it is often necessary to have members from each service to ensure agreement and compliance.

The activities of the infection control staff members, such as the ICP and the chairperson of the committee are generally performed, at least in principle, at the direction of the infection control committee. The responsibility of the ICP and the chairperson is to provide technical information and surveillance data, to draft policies for the committee's use in the final decision making process, and to carry out or promote many of the prevention and control measure adopted.

The infection control committee along with the QR or QA committee(s) should meet quarterly. Written minutes of these meetings should be kept in order to make certain that all recommendations and follow-ups are being carried out. The ICP should not keep the minutes because this person will have the responsibility of giving reports and keeping the agenda. Make certain that any problem(s) that is(are) discussed in one meeting, have been resolved and recorded in subsequent meetings.

The following is an example how minutes should be recorded:

Infection Control Committee

Health Care USA

Date of Meeting

Agenda

Time meeting began: ___

Members present: ___ (list full name and service)

Members excused: _____

Members not excused: ____

I. Call to order

II. Review/approval of Minutes

III. Old business: _____

Topic: Action: Discussion:

IV. New business:

Infection rate:

Previous quarter: ______

Last quarter: ______

Employee health: _________

Policy review: __________

Meeting adjourned: ____________________ (time)

Submitted by: Infection Control Practitioner signature ________________

Approved by: Chairperson's signature_____________________

The focal point for infection control activities in the nursing home is developing a system for surveillance which is designed to establish and maintain a data base which describes endemic rates of nosocomial infections. The term nosocomial infection is often used to describe hospital infections. Nursing homes should probably use facility-acquired infections rather than nosocomial infections. The purpose being is that many nursing homes are accepting patients from hospitals that are infected. So one should separate those that occurred within the facility (facility-acquired) from those residents admitted with a hospital infection (nosocomial). This will help in determining whether the hospitalized resident's organism has spread to other residents within facility.

An effective infection control program cannot be conducted without knowledge

of the specific and unique problems within nursing homes. Surveillance should ideally provide a systematic observation on the occurrence and distribution of facility-acquired infections among the residents for the purpose of prevention and control. The term surveillance implies that someone has compiled data to be examined and reviewed in order to determine problems that may exist within a certain environment.

Surveillance activities can provide valuable epidemiologic information such as:

1. Common organisms that cause infections
   
   

2. Shifts in microbial pathogens
   
   

3. Indigenous contamination/infection
   
   

4. Antibiotic resistant patterns
   
   

5. Employee's non-compliance to hygiene (handwashing)
   
   

6. Sources (personnel, environmental, resident population)
   

Surveillance activities may also provide the additional benefits of increasing the visibility of the infection control nurse within the facility. This will allow informal discussion of residents in a particular ward

A successful surveillance program is one that employs an infection control nurse to perform surveillance on clinical ward rounds, analyzes rates of infection, and uses the data obtained in making judgment concerning infection control practices. Once the data has been obtained over a period of time (minimal 6 months for nursing homes), the ICP can make a judgment on what infection control practices should be stressed.

1. Definition of infections
   
   
2. Systematic case finding and data collection
   
   
3. Tabulation of data
   
   
4. Analyze and interpret microbiology reports
   
   
5. Reporting of relevant infection control surveillance data to individuals and/or groups for appropriate action.

The ultimate outcome objectives of surveillance is to reduce the risks of facility-acquired infections among the residents. Thus when evaluating the need for a particular surveillance activity, eg. reducing urinary tract infections, or, limiting the spread of methicillin-resistant Staphylococcus aureus, the ICP should ask, can the information compiled by my system for analysis detect rises and spread of infections. This approach of analysis is termed "surveillance by objectives".

In order to translate surveillance efforts into infection prevention, it is necessary to identify and state intermediate, or process objectives that if achieved by surveillance will in turn reduce infection risks. Process objectives are often referred to loosely as the "uses of surveillance". For example, they may include such things as documenting baseline rates of endemic infections, identifying epidemics or other infection problems, convincing physicians or nursing home personnel of the seriousness of a particular problem and the need for vigorous control measures, evaluating the effects of control measures, reinforcing preventive resident care practices, satisfying standards, defending the nursing home against malpractice claims and litigation over facility-acquired infections.

The most fundamental use of surveillance is the measurement of base line rates of endemic facility-acquired infections. It should determine the ongoing risks in the nursing home, and act as a basis for other uses of surveillance. Examining rates of infection that are out-of-line would indicate problems. However, nursing home infection rates are not well known and should not be compared to hospital infection rates. In order to determine baseline infection rates for your facility, a 12 months (monthly rates) survey must be compiled by the ICP. The determination of any facility's baseline rates of infections is important. It should be done in a consistent fashion using the tools developed by the infection control committee.

The most frequently discussed use of surveillance is for the identification of epidemics. By regularly measuring the infections rates, one can determine deviations from the base line that sometimes represent epidemics due to a new common source of infection, the introduction of a new pathogen, or increased person-to-person spread from a breakdown in patient-to patient care practices. It has been argued that epidemics can often be recognized without the effort required for routine surveillance. 

The monitoring of baseline rates do provide two important advantages:

1. it allows fewer outbreaks to escape unnoticed
   
   

2. more infections are detected in the early stages of development

Nursing homes that have a well-organized surveillance system should have less facility-acquired infection problems. Perhaps the most important use of surveillance is to arm the infection control staff with sufficient information that will convince the medical staff, nurses and nursing home administrators the need for action. 

In order for this to be accomplished the following must be done:

1. provide information that will influence behavior
   
   

2. presentation of one self as an expert whose advice will be followed
   
   

3. provide definitive information that if these procedures are not followed, then these results will occur

How can the above be accomplished? The best way is to become thoroughly familiar with the scientific literature on nursing home epidemiology and infection control. When you are trying to influence a colleague, you can quote relevant literature to establish expertise and to provide convincing information. For example, a particular nursing home may not know the difference between colonization and infection when dealing with a resident that has cultured MRSA. This differentiation will influence placement of residents and may create unnecessary desocialization and segregation.

Once problems have been recognized through surveillance, potential risk factors have been identified and the staff members have been influenced to carry out either preventive or control measures, continued surveillance is usually necessary to ensure that the problem comes under control and will not return. What ever procedure was established for prevention or control should be written in the infection control minutes. Any follow-ups should also be placed in the minutes.

Remember feedback to your staff is important. If certain procedures were introduced because of a specific problem that surveillance detected, and your staff complied and the problem was reduced significantly or eliminated, then you should compliment your staff for a "job" well done.

A. Level

The level of surveillance should be tailored to the personnel and financial capabilities of the nursing home.

1. Definition

In order for consistent information to be collected, standard objective definitions for various types of infections should be used.

2. A basic form should be used for collection of data.

3. Periodic analysis of collected surveillance data is necessary.

4. Surveillance data should be put to use by the ICP, either by tables or graphs in order to demonstrate problems.

5. Surveillance and the ICP's exposure within the nursing home will remind personnel of the importance of adhering to good infection control practices.

6. Good continuing in-service educational programs should be developed by the ICP for all nurses, and ancillary personnel. A good in-service program on infection control should be developed by the ICP during orientation,

An effective infection control program must have a system to obtain information on residents who develop infections in a reasonable period of time. To control infections, one must understand them by examining the cause and effect patterns which emerge from the data that is collected by the ICP.

1. Rounds

The ICP must make rounds to resident care areas in order to talk with the nursing staff on any problems that have been recognized through surveillance. Remember that nursing homes do not have access to an in-house microbiology laboratory, do not have physicians constantly present for advice, and that many physicians who have nursing home patients do not always culture because of either cost-containment, or they may feel it is useless to obtain a culture (e.g. sputum for suspect pneumonia). So the ICP is at the mercy of his/or her staff to determine if there are active or incubating infections existing within the facility.

In order for the nursing staff to help you in detecting infections, they must be provided a copy and educated on the definition of infections.

Remember that ward rounds are supplemented by pharmacy records on antibiotic usage, temperature records, Kardex review, x-ray reports, microbiology reports, and comments by the physician in the medical record. It is important that the ICP can interpret microbiology reports.

2. Patient demographics

The type of patient demographics that the ICP should obtain during rounds are as follows:

1. medical record number (to ensure confidentiality, no names should be recorded)

2. age or date of birth

3. race (optional)

4. sex

5. admitting physician

6. attending physician

7. type of infection

8. site of infection

9. nosocomial infection?

10. facility acquired infection?

11. community acquired infection?

12. cultures taken

13. Gram stain performed

14. organisms isolated

15. susceptibility report

16. prior antibiotics before culturing

17. other laboratory tests (urinalysis, CBC, TB skin test, chest x-ray)

18. patient has a NG tube, requires respirator assistance, etc.

19. location of resident within facility

20. compromising conditions (diabetic, cancer, recent hospitalization or immunocomprised)

The ICP must devise a good table which answers all the questions concerning a particular resident. This will prevent endless trips to the charts for information not obtained from the initial round.

3. Calculating rates

Most acute care hospitals use the number of patients discharges in computing their nosocomial rates. Since the number of resident discharges from a nursing home is very low, the monthly census or even better the number of resident days is a more significant figure for computing infection rates.

For example:

St. Elsewhere Nursing Home had an average daily census of 90 for the month of March 2001.

The ICP found 7 total infections:

3 UTI

2 decubiti wound infection

1 aspiration pneumonia

1 conjunctivitis

The facility-acquired infection rate for the month of March 2001 was:

7/90 x 100 = 8%

or

7/(90 x 31) x 1000 = 2.5% infection rate per 1000 resident days

The same method of calculation can be used to determine the infection rates of nursing units or wings. The number of infections in a nursing unit is placed over the monthly census for that unit. Multiply the figure obtained by 100 to determine percentage.

One can also determine Attack Rates. Attack rates are a special kind of incidence rates. It usually expressed as a percentage. It is used for describing epidemics in which a particular population is exposed for a limited period of time.

For example:

100 residents were exposed to a contaminated lot of green beans over a 10 day period and 20 of these residents developed food poisoning.

Attack rate = 20/100 = 20%

Another example where attack rates may prove useful would be to evaluate the risk of urinary tract infections among catherized residents.

There are many nursing homes that can not perform daily surveillance because they lack a full time ICP. A Prevalence Rate could be used instead of an incidence or infection rate. This is the percentage of residents in a population with a facility-acquired infection rate at any given time.

For example:

A surveillance program at John L. Smith Health Care was performed on the 2nd Wednesday of each month. The ICP on March 14, 2001 found 5 infections. The census on that particular day was 90.

The prevalence rate would be:

5/90 x 100 = 5.5%

The prevalence rate identifies the number of infections at a particular point in time. All available charts of residents with an infection are systematically reviewed, and any resident with an infection is identified and documented.

What ever rate system is used, the ICP must recognize the fact that she/he must be consistent in determining infections. Otherwise it will be difficult to assess data as to infection rates or existing problems occurring within the facility.

It is also just as important that the ICP can interpret microbiology data. Colonization vs. infection is often confused by many ICP's in the nursing home setting. For example, the finding of Staphylococcus aureus in sputum does not automatically indicate bacterial pneumonia by this organism. Other factors have to be looked at before deciding such as: elevated temperature, abnormal CBC, abnormal chest x-ray, heavy growth of the organism on culture, and the presence of many WBC and gram positive organisms predominantly in clusters seen on the Gram stain.

Have your reference laboratory give you an in-service on how to interpret microbiology reports.

Always perform monthly evaluation of your data even though the committee may assemble quarterly. Do not wait to the last minute (the night before) to tabulate your results.

You may also want to look for seasonal trends. Seasonal trends are annual variations of occurrence of a particular disease. For example, the increase of respiratory distress among residents may be due to allergic manifestations. This may be due to poor ventilation or dirty vents. Many nursing homes have problems with heat and humidity. The increase number of conjunctivitis could be due to excess dryness. Personal hygiene during these hot periods could contribute to endogenous contamination of Escherichia coli of the eyes through anatomical transfer (fecally contaminated hands and rubbing eyes).

Never compare monthly infection rates with other nursing homes, corporate facilities or hospitals. Every health care facility and hospital have their own methods of obtaining information. If a comparison is going to be made, both the methods of surveillance and interpretation should be reviewed first.

When an infection control report is given to a committee, it should contain the following information: data from the previous month or quarter, data from the last committee meeting and data from the previous year for comparison.

Example of an infection control report:

Average Infection rate for 1st quarter(2000): 3.8%**

If you have any questions concerning this section of the manual, please call my home office for assistance.