Infection Control

Overview | Infection Control Practices | Outbreak Control | Quality Improvement | Disease Topics | Related Tags | Additional Resources | Bibliography | Reviewers | Feedback

Overview

The DADS Quality Assurance and Improvement vision for infection control in Texas LTC is

To discourage the occurrence and spread of facility-acquired infections.

This page addresses general principles of infection control in LTC facilities. Illness-specific infection control practices that are effective in discouraging the emergence or transmission of specific infections are highlighted in the accompanying disease topic pages that are linked to this root page. Together, these comprise the best practice framework for infection control.

Infections acquired in healthcare facilities are the cause of significant illnesses and deaths among nursing home residents. In 1989 the Centers for Medicare and Medicaid Services (then the Health Care Financing Administration) began requiring LTC facilities to maintain infection control programs in order to reduce the incidence of such infections.[1] The purpose of these programs was to protect both residents and nursing home employees. While most LTC facilities have instituted some type of infection control committee, the activities and effectiveness of these committees varies.[2]

Understanding How Infections Spread: The Cycle of Contagion Model

Figure 1: The Cycle of Contagion model.

The cycle of contagion begins when a disease-causing agent or pathogen such as a virus or bacteria enters a facility. A resident, staff member, visitor or even an inanimate object can introduce pathogens into a facility. The pathogen finds its way to a susceptible person, and that person becomes a host for the pathogen. LTC residents are generally more susceptible than staff because of age-related physiological changes, health problems and impaired mobility. The pathogen may multiply in the host without causing injury; this is called colonization. If the pathogen attacks host tissues, it causes the symptoms of infection.

Any environment in which the pathogen can survive and multiply becomes a reservoir. Reservoirs serve as potential sources for the pathogen. A person or even an inanimate object can act as a reservoir. Although both colonized and infected hosts may spread the pathogen, the cause of spread is often the persons caring for affected individuals. Staff members and other caregivers become either contaminated or colonized while caring for affected residents and then unknowingly carry the pathogen from one resident to the next.

Different infectious illnesses are transmitted in different ways. They may be spread by contact, droplet, airborne, common vehicle, or vector (e.g., insects or vermin) modes of transmission. For example, pathogens such as respiratory viruses may be easily transmitted hand-to-hand or in droplet form. Thus, without infection control measures that interrupt these specific modes of transmission, a respiratory infection such as influenza can spread rapidly throughout a facility affecting both residents and staff.

Infection Control Practices

The purpose of infection control is to prevent new infections when possible and to identify new infections and halt their spread whenever prevention is not possible. The types of actions that can prevent infections and halt their spread can be identified from the cycle of contagion model. These actions shown in the model are not necessarily effective against every pathogen. The model serves best as a general framework for thinking about how these interventions help in infection control rather than as literal instructions on how to approach infection control for any pathogen. The infection control actions include the following:

1. barring the entry of a pathogen into the facility,
2. quickly identifying contagious illness through active surveillance,
3. protecting individuals against specific pathogens through immunization or chemoprophylaxis, and
4. treating individuals to eradicate colonization or infection, and
5. interrupting transmission through hygienic measures such as handwashing, environmental decontamination, and ventilation control.

The relative importance and effectiveness of each type of measure depends on the specific illness. For example, post-exposure vaccination is of greater benefit for some illnesses than it is for others, and not all individuals that receive a vaccine against a particular infectious illness develop effective immunity. In addition, the use of decolonization may be appropriate in only a few exceptional circumstances. Figure 2 below shows where these measures fit in relation to the cycle of contagion.

Figure 2: Interrupting the cycle of contagion to halt the spread of disease.

Surveillance

Surveillance is a cornerstone of infection control in LTC. It is used to detect infections, plan control activities, and prevent outbreaks.[3] Effective surveillance consists of data collection, data analysis, data reporting, and decision making.[12] See the Centers for Disease Control and Prevention for still more information concerning disease surveillance.

Prevention and Containment Principles

Prevention and containment encompass activities that aim to halt the spread of pathogens and the infections they cause.

Hand hygiene: Handwashing is the most important practice for reducing transmission of microorganisms that cause infections in the LTC setting. Washing hands thoroughly and often reduces the risk of infection.[5] Handwashing with soap and warm water for at least 15 seconds is generally effective in removing microorganisms from the hands.

Universal Precautions: Universal precautions are designed to prevent transmission of the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other pathogens that are spread through contact with body fluids. For a detailed list of body fluids that should be handled with universal precautions see the CDC Recommendations on Universal Precautions. Universal precautions require the use of protective barriers (e.g., gloves, gowns, aprons, masks, and protective eyewear) whenever exposure to bodily fluids is possible.

Isolation and Barrier Precautions: These precautions establish physical barriers to the spread of contagious diseases.[5,6] The related infection control practices include:

• Hand hygiene: Wash your hands before and after caring for each resident - no exceptions. It may also be necessary to wash hands between activities on the same patient (e.g., providing oral hygiene and a dressing change). Handwashing is the most important practice for preventing the transmission of contagious illnesses.
• Gloves: Use gloves only once. Change them before working with another resident. Do not handle equipment or devices with contaminated gloves. Always wash your hands after removing gloves. Gloves are supplemental protection rather than a substitute for proper handwashing. Use gloves whenever you could come in contact with:
  • Mucous membranes
  • Non-intact skin
  • Body fluids (e.g., blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items soiled with these substances).
• Face and eye protection: Use face and eye protection whenever there is a possibility of splash exposure to body fluids such as when using suctioning devices, emptying fluids, performing wound irrigation, and similar resident care activities.
• Aprons or gowns: Use an apron or gown whenever your clothing could become contaminated or soiled with pathogens that are readily transmitted by direct contact.
• Resident isolation: While isolation is sometimes needed to break the cycle of contagion, it should only be used when medically necessary. Your infection control policy should ensure that nursing staff have the authority to make immediate isolation decisions pending specific physician orders.

Employee Health

Your LTC employee health efforts must educate employees about how to protect their own health, prevent workplace-acquired infectious illnesses, and prevent the spread of infections in the facility. All new employees should have a health evaluation and should receive specific instructions on how to prevent the transmission of infectious illnesses to other staff and residents. Employees should also be instructed on the facility infection control policies and practices that address:[7]

• Viral hepatitis (hepatitis B and C)
• Human immunodeficiency virus (HIV)
• Tuberculosis
• Influenza
• Streptococcal and staphylococcal infections
• Gastrointestinal infections
• Scabies
• Herpes zoster and chickenpox
• Pertussis (whooping cough)
  

Immunization

The purpose of immunization is to reduce the susceptibility of residents and staff to certain infections. Immunization recommendations differ for employees and residents (see CDC Guidelines and Recommendations for Immunizations).

Residents should be vaccinated against:[8,9]

• Tetanus / diphtheria: The elderly are at an increased risk for acquiring tetanus because of vascular insufficiency, skin ulcers, and diabetes mellitus. The highest risk of tetanus is in individuals over 60 years of age. Therefore, all LTC residents should be immunized for tetanus every ten years. The combination Td immunization covers both Tetanus and diphtheria conferring adequate protection when given every ten years.
• Influenza: Influenza occurs sporadically, in annual outbreaks and in epidemics. It is a significant cause of illness and deaths among elderly LTC residents. It is highly infectious and easily transmitted in LTC facilities. Provide annual vaccination against influenza unless there is a specific contraindication. See the influenza framework for additional information.
• Pneumococcal pneumonia: Pneumococcal pneumonia is a leading cause of mortality in the elderly. All residents less than 65 years old should receive pneumococcal vaccine (0.5 ml IM) if they have not had the vaccine in the past 5 years, have not already had two pneumococcal vaccinations and have no contraindication to the vaccine. More than one revaccination in adults is not recommended. Revaccination for individuals 65 and older is recommended only for those who were vaccinated more than 5 years ago AND who were less than 65 at the time that they received the initial dose. See the pneumonia framework for additional information.

Employees should be vaccinated against:

• Influenza: Annual vaccination is recommended because LTC staff who develop Influenza often spread the infection to LTC residents.
• Hepatitis B: Vaccination is recommended for LTC staff that may be exposed to blood or body fluids - particularly if sharps are used in the care of residents (e.g., collecting blood, administering injectable medications or performing wound debridement).
• Routine Adult Immunizations: See ACIP age-specific immunization recommendations.

Outbreak Prevention and Control

Every LTC facility should have an administrative framework for managing outbreaks of infectious illness. A single case of transmissible infection (e.g., TB, influenza, VRE or MRSA infection) should raise the alarm of a potential outbreak. Notify the medical director, director of nurses, administrator, and infection control practitioner concerning any suspected case. Search for any additional cases. Your response to the initial case must address the infection containment as well as treatment and prophylactic measures appropriate for the specific illness. There are tools that can help you respond to outbreaks quickly and effectively; examples include:

• A centralized record showing the immunization status of each resident.
• A case log and outbreak summary of the information that you need to in order to track and contain the outbreak.
• A facility floor plan showing staff assignments.

Practical Guide to Quality Improvement

Key Components of Successful Infection Control Programs

The following recommendations address general infection control practices that are not disease specific. Disease-specific quality improvement recommendations appear in the accompanying disease-specific pages.

Part I. Develop an Infection Control Committee and Designate an Infection Control Practitioner

All LTC facilities should develop an infection control committee (ICC), designate an infection control practitioner (ICP), and develop an administrative framework of policies and procedures to deal with infection control issues. The infection control committee (ICC) should include:

• The infection control practitioner (ICP),
• The facility medical director,
• Member(s) from the nursing, administrative, and pharmacy staffs, and
• Additional members as needed from physical therapy, respiratory therapy, dietary, human resources, housekeeping, and maintenance.

The functions of the ICC should include:

• Identifying the ICP - a staff member who is:
  • Familiar with LTC residents and their health issues.
  • Knows the applicable local, state, and federal regulations concerning infection control in LTC.
  • Knows the applicable federal (OSHA) and state occupation regulations.
  • Able to implement, monitor, and evaluate the effectiveness of the facility's infection control system.
  • Competent to oversee the surveillance system, provide staff education, and assess the effectiveness of the facility's infection control system.
• Developing an authority statement for the ICC/ICP to provide decision-making authority in order to interrupt the transmission of infectious disease. For example, the ICC/ICP require the authority to:
  • Close a unit or ward to further admission in case of a suspected or actual outbreak.
  • Relocate and isolate residents to prevent transmission of disease.
  • Restrict visitors when absolutely necessary.
  • Restrict movement of residents from one ward to another when such restrictions are medically necessary.
  • Notify local, state, and federal public health agencies of reportable illnesses and outbreaks as required by law.
• Developing written policies and procedures:
  • For all infection control issues.
  • Control of specific infections (e.g., influenza, pneumococcal infection, Clostridium difficile).
  • To periodically review, revise, and update policies and procedures.
  • To periodically measure staff awareness of and adherence to infection control polices and procedures.
  • For staff education concerning infection control policies and procedures.
• Obtaining specific infection control policies from individual departments regarding items under their responsibility.[11]
• Meeting on both a regular and as-needed basis to:
  • Discuss current infection control issues.
  • Anticipate and plan for seasonal patterns of infectious disease (e.g., address mosquito-borne infections in the summer, organize an effective immunization plan for Influenza in the fall).
  • Review surveillance findings, identify disease trends, and act accordingly.
  • Address an emerging outbreak.

Part II. Surveillance

Proper surveillance requires objective, timely, and valid definitions of infection. Effective surveillance requires knowing both the number of current infections (i.e., the baseline) and the number of new infections that occurred during the reporting period (e.g., weekly). Surveillance involves ongoing collection, analysis and reporting of data as well as making decisions based on that data.

Establish a Surveillance System[3]

• In order to conduct purposeful surveillance, you must determine:
  • The infections that your facility wants to identify and track.
  • The type of information needed to identify those illnesses.
  • The processes and procedures needed in order to collect the information you need.
  • The triggers for data collection. Triggers are potential clues to infection; they may include: fever, specific symptoms, certain physician orders such as cultures or antibiotic medications, and certain laboratory test results.
• Identify your sources of data. These may include:
  • Reports from staff.
  • Other ICP professionals in nearby facilities.
  • Residents' medical records.
  • Your independent resident assessments.
• Follow-up on all transfers of residents to acute care facilities. Was infection the cause of the transfer? Has the resident acquired a nosocomial infection during the hospital stay?
• Adopt written definitions for diagnosing nosocomial infections.
• Collect data on an on-going basis (see sample surveillance worksheet). Review and analyze your data at least monthly and more often during suspected outbreaks.

Analyze Surveillance Data

Analyze your surveillance data. Compare individual case data with the definition of infection established for a particular illness.[3]

• At the first sign of infection, complete a surveillance worksheet to document the infection site, signs and symptoms, diagnostic test results, and follow-up comments and notes.
• Examine your worksheet data for clinical and geographic trends. Are most of the cases on a particular hall or wing? Are several residents having similar symptoms? Look for the features that these residents have in common (e.g., gender, caregivers, devices, treatments).
• Keep accurate records of all infections within your facility. Use electronic worksheets such as spreadsheets to simplify sorting, searching and grouping of data.
• Compute the rates of new infections in your facility.
• Monitor your facility's Quality Indicator for Urinary Tract Infections (UTI)
  • Identify which of these infections are related to indwelling bladder catheter use
  • Indentify UTIs that involve unusual or high risk pathogens such as VRE, MRSA or other pathogens with unusual antibiotic resistance
• Evaluate your surveillance data at least weekly and whenever there is a sudden increase in the number of infections or a new type of infection. Look for emerging trends in your data.
• Look for clusters of residents with similar symptoms, type of infection, or physical location within your facility. Determine the similarities among affected residents.
• Compile and share surveillance data and statistics with the medical director and ICC at least quarterly and whenever there are new trends or suspected outbreaks.
• Use your surveillance information to identify and address infection control issues.
  • Infection rates for a particular disease during the same months across consecutive years suggest seasonal patterns.
  • Infection rates in consecutive months during the year suggest emerging trends.
  • Differences in infection rates among your nursing units should lead you to seek reasons for the observed differences.

Making Decisions Based on Surveillance Data

Surveillance data are important in determining which infection control practices need to be reviewed. Therefore, it is important to make surveillance data available in a way that helps the infection control committee make those decisions.

• Focus on new cases of infection.
  • Determine whether these were present on admission or acquired in the facility.
  • Determine whether they are contagious. If so, find out how transmission occurs.
  • Determine how long it is before a newly infected person usually develops symptoms (the incubation period) in order to anticipate which other residents may be affected.
  • Consider whether other residents may have already been infected or colonized.
  • Determine the type of actions you need to take to halt the transmission of infection.
  • Decide whether you need to meet with the medical director or call a meeting of the ICC.
• Prepare a report for members of the ICC, administration, medical director, and nursing staff at least quarterly and whenever an outbreak is suspected. Your report should include:
  • A written summary of infections that occurred since the last report date.
  • Summary rates for all nosocomial infections that have occurred since the last report.
  • Simple graphs that show infection trends.
  • Counts and rates of infection as needed.
  • Your recommendations for actions that need to be taken.
    • What procedures need to be implemented to halt a newly identified outbreak?
    • Is there a need to provide staff education for these changes?

Part III. Prevention and Containment

The purpose of prevention and containment activities is to halt an outbreak of contagious infection. The primary prevention procedures are handwashing, universal precautions, and isolation precautions. When an outbreak occurs, take specific actions based on the specific disease.

• Confirm the suspected diagnosis with the appropriate diagnostic tests.
• Implement outbreak control procedures.
  • For notifiable diseases, notify the local health department within the required timeframe, and coordinate your investigation with the local health department.
  • For diseases that are not reportable, the facility medical director and ICP should investigate the suspected outbreak documenting all laboratory-confirmed and suspected cases. [Note: the reviewer for this framework recommends notifying the local health department of every suspected outbreak regardless of whether it involves a reportable disease.]
  • Knowing the mode of transmission for this disease, look for the actual cause of transmission. Is there a break in infection control procedures? Identify and remedy it.
  • Take specific actions to interrupt cycle of contagion in order to halt the outbreak.
    • Alert all staff and remedy any breaks in routine infection control procedures.
    • Provide medical treatment for infected individuals when that is warranted.
    • Quickly initiate vaccination and/or chemoprophylaxis when that is appropriate.
    • Speak candidly about the outbreak with residents, their families and visitors so that everyone will cooperate with your efforts to halt the outbreak. The SARS outbreak of 2003 in China is one of many examples of how silence and denial lead to delayed containment, avoidable illness and needless deaths.

Disease Topics

The following pages offer additional disease-specific infection control information.

• Influenza
• Methicillin Resistant and Vancomycin Resistant Staph aureus (MRSA & VRSA)
• Vancomycin Resistant Enterococcus (VRE)
• Clostridium difficile Disease (C. difficile)
• Tuberculosis (TB)
• Pneumonia
• Foodborne Illness

Related Licensure and Certification Tags

The following deficiencies may be cited for failure to employ appropriate infection control. The deficiency list is representative rather than exhaustive.

Program	Licensure Tags (State)	Certification Tags (Federal)
Nursing Facilities	19.601(c) F224 Neglect 19.801 (1) F271 Admission Orders 19.801(2)(A)(B)(xiv) F272 Comprehensive Assessments 19.801(2)(C)(i) F273 Comprehensive Assessment within 14 day of admit 19.801(2)(C)(ii) F274 Assessment following Significant Change in Condition 19.801(3) F276 Quarterly Review 19.801(7) F278 Accuracy of Assessment 19.802 (a)(1)(2) F279 Comprehensive Care Plans 19.802(b)(3) F280 Review and Revising the Care Plan 19.802((d)(1) F281 Services Meet Professional Standards of Quality 19.802(d)((2) F282 Implementation of Care Plan 19.901 F309 Quality of Care 19.901(4)(B) F316 Bladder Function/UTI 19.901(12)(A)(i-vi) F329 Unnecessary drugs 19.1501(2) F426 Pharmacy Services 19.1501(4)(A) F428 Drug Regimen Review 19.1501(4)(B) F429 Irregularities reported by the Pharmacist 19.1501(4)(B) F430 Reports Acted Upon 19.1501(6)(A)(B) F432 Storage of Drugs 19.1504(a-g) Drug Security/Self Administration 19.1601(1)(A)(B)(C) F441 Infection Control 19.1908(b)(2) F505 Physician Notification of Lab Findings
ICFs/MR	M0015 90.42 (c) W322 Preventive and general health care M0015 90.42 (c) W363 Irregularities in drug regimen
Assisted Living	92.41(a)(4)(D)(iii-iv) In-Service provided to the staff 92.41(c)(1)(P) Resident assessment for medications 92.41(e)(1)(A) Admission and Retention of Resident whose needs cannot be met by the facility 92.41(j)(1-6) Medications 92.41(n)(1) Infection Control 92.101 Neglect of a Resident

Additional Resources (including online resources)

The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit, and non-profit sources. Some of these sources may have financial ties to industry. DADS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.

Online

CDC Fundamentals of Isolation

CDC Emerging Infectious Diseases: Preventing Infections in Non-Hospital Settings: Long-Term Care (Lindsay E. Nicolle; University of Manitoba, Winnipeg Canada)

Texas Department of State Health Services

Texas Administrative Code: Nursing Facility Requirements for Licensure and Medicaid Certification: Infection Control, Vaccinations

In Print

Smith PW. Infection control in long-term care facilities. 2nd ed. Delmar Publishers, Inc.,: Albany, NY.

Bibliography

[1] Makris AT, Morgan L, Gaber DJ et al. Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities. American Journal of Infection Control 2000;28(1):3-7.

[2] Goldrick BA. Infection control programs in skilled nursing long-term care facilities: An assessment. American Journal of Infection Control 1999;27(1):4-9.

[3] Rusnak PG, Horning LA. Surveillance in the long-term care facility. In: Smith PW (Ed.). Infection Control in Long-Term Care Facilities. 2nd ed. Delmar Publishers, Inc.,: Albany, NY. 1994:117-130.

[4] Pritchard V. Joint Commission standards for long-term care infection control: Putting together the process elements. American Journal of Infection Control 1999;27(1):27-34.

[5] Pritchard VG. Infection control measures to block transmission: Isolation and beyond. In: Smith PW (Ed.). Infection Control in Long-term Care Facilities, 2nd edition. Delmar Publishers Inc.: Albany, NY. 1994:227-251.

[6] Centers for Disease Control and Prevention Recommendations for Isolation Precautions in Hospitals. Accessed 1/12/2006.

[7] Crossley KB. Infection control aspects of the employee health program. In: Smith PW (Ed.). Infection Control in Long-term Care Facilities, 2nd edition. Delmar Publishers Inc.: Albany, NY. 1994:193-200.

[8] Stern JK, Smith PW. Infection control measures: the resident. In: Smith PW (Ed.). Infection Control in Long-term Care Facilities, 2nd edition. Delmar Publishers Inc.: Albany, NY. 1994:203-210.

[9] Centers for Disease Control and Prevention Adult Vaccine Schedule. Accessed: 5/31/03.

[10] Smith PW. Infection control program organization. In: Smith PW (Ed.). Infection Control in Long-term Care Facilities, 2nd edition. Delmar Publishers Inc.: Albany, NY. 1994:105-115.

[11] Haberstich NJ. Infection control measures: The environmental resevoir. In: Smith PW (Ed.). Infection Control in Long-term Care Facilities, 2nd edition. Delmar Publishers Inc.: Albany, NY. 1994:211-226.

[12] Smith PW, Rusnak PG. Infection prevention and control in the long-term-care facility. American Journal of Infection Control 1997;25(6):488-512.

Reviewers

Reviewer comments that could not reconciled with available research literature or regulatory requirements appear in this framework in brackets, in navy blue italics, and are attributed to the reviewer. All other reviewer comments have been assimilated as modifications to the framework.

Peer Reviewer: Neil Pascoe, RN
Mr. Pascoe is a nurse epidemiologist in the Infectious Disease Epidemiology and Surveillance (IDEAS) Division of the Texas Department of State Health Services.
Review Date: September 15, 2003

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Last updated: December 24, 2003
Links updated: November 29, 2004
Added link to TAC on Infection Control: March 23, 2005
Repaired links: Jan 12, 2006