New resources for providers aimed at increasing knowledge and decreasing infections in long-term care facilities.
When it comes to purchasing infection prevention supplies, acute care facilities and long-term care facilities are very different entities to interact with.
Hospitals have product selection committees, and the infection preventionists at the hospitals are always on them. But long-term care purchasing isn’t structured the same. At most facilities, it’s parceled out among many different people.
“A lot of times, you either have a corporate person purchasing for the facilities, plural, or you have a competent materials manager who I fondly call ‘George in the Basement.’ He’s your materials person, and orders cleaner disinfectants with everything else,” said Deb Burdsall, manager, Infection Prevention at Baldwin Hill Solutions LLC in Palatine, Illinois, and a board member of the Association for Professionals in Infection Control and Epidemiology (APIC). “Then you have another person ordering for dietary, another ordering for environmental services, and one more person ordering for nursing.”
Burdsall said it’s important for distributor reps who call on long-term care facilities to ask and determine who makes the decision to buy something, who signs the check, and then who uses it, “because a lot of those people aren’t all at the table,” she said. “They just get what they get.”
And often there is not just confusion in what they are getting, but how they should be using it – because though the way they purchase products isn’t the same, the patients they serve often move back and forth from one setting of care to the other.
Last spring, the Centers for Medicare & Medicaid Services (CMS) issued new requirements for skilled nursing facilities on the use of enhanced barrier precautions (EBP) to help prevent infections. EBP involves the use of personal protective equipment (PPE), specifically gowns and gloves, during high-contact resident care activities, such as assistance with bathing, dressing, or toileting.
Given that the CMS requirements are relatively new and there is some ambiguity regarding their implementation, APIC believed it was important to provide clarity for healthcare workers, said APIC CEO Devin Jopp, EdD.
In December, APIC, in collaboration with the American Association of Post-Acute Care Nursing (AAPACN), released a practice guidance tool and resource guide to help healthcare personnel in skilled long-term care facilities implement enhanced barrier precautions (EBP).
“The new tools from APIC and AAPACN are intended to assist healthcare professionals in carrying out the new EBP requirement, with the goal of safeguarding nursing home residents from infection,” Jopp said.
Vulnerable population
Residents in long-term care facilities often have weakened immune systems due to age, chronic illnesses, or other health conditions, making them more susceptible to infections, according to the Centers for Disease Control and Prevention (CDC). Close living quarters and shared spaces – for long periods of time – increase the risk of spreading infections among residents and staff.
“With long-term care, even a short-stay patient, rehab patient can have up to a hundred days sometimes, depending on what’s wrong with them,” Burdsall said. “There are more short-stay patients now than there were 15 to 20 years ago. But it’s still a situation where for a lot of people, it’s their home, because that was the original focus of long-term care. A lot of the rules and regulations focus on person-centered care, home-like, least restrictive environments.”
EBP measures are used specifically in the skilled long-term care setting to allow for flexibility in the care of residents while also minimizing the risk of transmission of multidrug-resistant organisms (MDROs).
According to CMS, EBP are indicated for residents with any of the following:
- Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or
- Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage like a Band-Aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility.
Facilities have discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC, CMS said.
APIC and AAPACN saw that EBPs require a lot of critical thinking at the point of care, thus their issuing of guidelines.
“If you’re in contact precautions, you put a gown and gloves on before you go in the room,” Burdsall said. “If the person is on EBP and you’re going to go in to drop off a tray, hand somebody some mail or talk to them, all you need is hand hygiene; whereas if you need to get up close and personal, then you need to put a gown and gloves on. This is a challenge to teach, a challenge to train, and a challenge for the surveyors to survey.”
Certain states and their surveyors have gotten black and white about EBP, so AAPACN partnered on the guidelines and gained approval from both CMS and the CDC, Burdsall said. “So now there’s some guidance for the surveyors when they go in that’s short, sweet and to-the-point … The goal is to create the least restrictive environment for person-centered care, isolating the germs and not the person.”
APIC’s practice guidance tool outlines when EBP should be implemented for residents, provides infection control recommendations for routine care activities, and includes case study examples with a self-quiz to help reinforce learning. The resource guide provides a comprehensive list of infection control websites and references. Both tools are available free from the APIC website.
The need for more dedication
Infection prevention in long-term care has traditionally been an additional responsibility assigned to nurses without specialized training, Burdsall said. Fortunately for her, she loved and found a vocational calling in the role and responsibilities. But others assigned to infection preventionist duties may not be as passionate or have the time necessary to dedicate to the position.
However, dedicated infection preventionists are now recognized as crucial, with rules in many states mandating proper training and time allocation for these roles.
Long-term care facilities must use cleaning and disinfecting products that are healthcare-rated, as generic products from big-box stores may not be effective or safe for healthcare environments. Staff must be trained on the proper use of these products.
Infection preventionists should work with suppliers to find cost-effective solutions for cleaning products. It’s important to avoid purchasing cheaper, non-healthcare-grade products based on personal relationships with distributors.
Education on proper environmental cleaning and disinfecting is critical, as it’s not something typically covered in nursing school. This education helps ensure that cleaning protocols are followed correctly to prevent the spread of infections.
“We’re slowly getting to where people realize that they need somebody who’s dedicated to that position, that it’s not just designated,” she said.
Infection control resources
APIC resources for healthcare professionals working in long-term care include LTC Certification; LTC Essentials Training; the APIC Text, a comprehensive, 125-chapter, infection prevention and control (IPC) reference reflecting the latest guidance in the field; and PolicyPro, which includes customizable IPC policy templates developed by infection prevention and regulatory experts.
For more information, visit apic.org.