It's time to immunize residents and staff against the flu...have you prepared your facility?
As we enter October, it's time to make sure you have prepared your facility for the coming flu season. Have you...
Trained staff on the risk of the flu, flu prevention, and early detection to prevent spread?
Ordered enough flu vaccine to immunize your residents and staff?
Planned to get medical orders and consents for resident immunizations?
Educated your family members and other visitors on the facility flu prevention program?
Influenza Resource Center
Presention and Control of Influenza in Senior Care Communities: Silverchair Learning Systems is offering a computer based learning module on the prevention and control of influenza free of charge. This module cannot be downloaded, but could be used individually by staff in your facility or presented to groups of staff if you have access to a computer projector. To give as a group presentation, log onto the program and connect your computer to a projector and present to the group. To access the program, go to Influenza Prevention Protocols for Senior Care . Posted 01/28/06
CDC Interim Guidelines on Antiviral Medications for Influenza are available at http://www.cdc.gov/flu/professionals/treatment/0506antiviralguide.htm . These recommendations, updated in mid-January, reflect the drug resistence to some therapies identified in 80% of cases this season. The National Clearinghouse of Guidelines updated it's analysis of immunization and chemoprophylaxis, including a discussion of how to respond to influenza outbreaks in institutions and is available at http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9473 .07-21-2006
Checklist Available for Pandemic Flu Preparedness has been prepared by Centers for Disease Control specifically for long term and continuing care settings and can be downloaded for free by clicking HERE. For more information on the pandemic flu risk, go to www.pandemicflu.gov . 07-19-2006
CDC Weekly Flu Update
For a weekly update on the spread of influenza, visit the Centers for Disease Control Weely Flu Update page. Keep alert to the incidence of influenza in your service area, and be alert to the reporting of respiratory symptoms with fever and malaise in your daily resident care reports. Keep in mind that immunosuppressed elderly patients will not have the same aggressive manifestation of fever that is seen in younger flu patients. Be alert for more suttle signs that they may be afflicted.
Guidelines for Isolation Precautions
The CDC Infection Control Practices Committee has updated their recommendations for infection control practices. These recommendations are included in their publication Guidelines for Isolation Precautions and Transmission of Infectious Agents in Healthcare Settings 2007. Of note is the committee's addition of new elements of standard precautions. These inlcude: Respiratory hygiene and etiquette Safe Injection Practices Use of face masks for catheter insertions The document also reviews the approriate strategies for transmission based precautions, including Contact Precautions, Droplet Precautions, and Airborne Precautions.
Long term care facilities offer a possible source for the transmission of TB from patient to patient. While TB is not terribly resilient in the environment, the close proximity of immunocompromised hosts offers an increased risk. For this reason, long term care facilities have traditionally been vigilant on the detection of TB to prevent an outbreak. Some states, such as New York, have discontinued the annual PPD testing requirement for all residents, as long as staff are oriented to the signs and symptoms that must be observed for and that testing is initiated if indicated. Other states still require annual testing.
OSHA requires that health care workers be tested annually, and that workers in high risk categories be tested more frequently as indicated. For example, nurses working on a prison health unit that may have a higher incidence of TB exposure, might be tested every six months instead of annually. Your facility's infection control manual should include a risk assessment of your setting and a determination of frequency of staff testing based on those risks.
Clostridium Difficile has been on the rise in both hospitals, and the nursing homes they refer to. While this infection is well known to health care professionals for many years, there have been some resistant strains that have grave outcomes, and the overall incidence has been on the rise because of aggressive antibiotic usage in hospitals.
This article reviews some important facts about Clostridium Difficile, and some implications for continuing care settings.
1. Assume that all hospital admissions to the nursing home are at higher risk for developing C-diff. The rate of infection in hospitalized patients has been on the rise throughout the country, and the infection may be present several days before the diarrhea symptoms develop.
2. Consider C-diff in any resident who develops diarrhea after a course of antibiotics. In about 5% of the population, C-diff is cultured in the intestines. When patients who are cultured with C-diff receive antibiotics, the other intestinal flora are disrupted and the C-diff can proliferate.
3. Wash hands thoroughly with soap and water before and after contact with patient with C-diff. The spores that cause C-diff are vulnerable to soap and water washing. They are resistant, interestingly, to alcohol based hand cleaners.
4. Provide private rooms for patients with C-diff, or cluster infected patients together. While C-diff is not spread by airborne pathogens, it is very easy for spores to spread in the environment.
5. Terminally clean thoroughly any bed that has been occupied by an infected patient. There are special cleaners specifically designed for C-diff. There is a two step process-- the first step breaks open the spores, and the second kills them.
6. Refer C-diff infected patients for aggressive medical management. They are usually treated with either Vancomycin or Flagyl depending upon the situation. Drugs which reduce gastric transit may actually slow the delivery of medication to where it is needed. Fluid support is needed to prevent dehydration. Infectious disease consultation should be considered if patient has not responded to therapy in several days. (These are general guidelines and are not intended to take the place of advice of your medical provider).
As with all infections, it is important to track the incidence and spread in the facility. Determine if each case is community (or hospital) acquired, or facility acquired (nosocomial). Reinforce handwashing and the other infection control measures listed above with staff caring for these residents. Doing so may be all that stands between your facility and a serious outbreak.
For more information, check the CDC website on C-diff.
Five Steps to Effective Infection Control in Long Term Care
Probably no other category of illness has such major implications or unpredictability of outcome for a health care provider than infection and septic shock. A "simple" urinary tract infection can evolve into urosepsis and a resource intensive course of therapy in critical care. Urosepsis alone is the major cause of death of adults over 65.It is for this reason that prevention of this complication must be one of the health care provider's highest priorities. Being vigilant to preventive measures is imperative. Something as simple as handwashing is critical to the spread of infection. But so often, this simple approach is neglected. As the health care provider tracks and trends lengths of stay and tries to identify variances which result in a longer stay than anticipated, infection should always be considered. When looking at infections, it is important to differentiate between community acquired and nosocomial infections. For example, when looking at pneumonia in a subacute setting, it is important to differentiate between an increase in pneumonia in the general population during the flu season, and infections which may be acquired in the facility due to care related issues. The way to differentiate the two is line listing of infections. For each patient with an infection, list the site of infection, the organism, sensitivity report, date of admission and date of symptoms onset. Then categorize together all of the patients with the same site and organisms, then drop off the infections which occurred within 48 hours of admission (not enough time for incubation of a nosocomial infection). Then take the patients with the same site and organism and look at the sensitivity reports. If the sensitivity to antibiotics is variable, it is unlikely that the infections came from a single source. If on the other hand, the sensitivities are identical, it is unlikely that they were randomly acquired community infection. Once sepsis occurs, aggressive monitoring, antibiotic therapy, and fluid management are critical for successful outcome. In some cases, the timely diagnosis of infection initiation of antibiotic therapy can make the difference between life and death. Ineffective management can result in extended periods of illness. Cost issues regarding antibiotic therapy can be complicated. A tradition step approach to antibiotics, starting with standard and less expensive ones and then advancing to newer, more expensive ones if they don’t work may seem cost effective. But if going to the newer "big guns" earlier may result in shorter period of illness and need for critical care. On the other hand, if you jump to the "Big Guns" and they don't work, where do you go next?
These steps should be followed in the continuing care setting to ensure that infections are controlled:
Monitor new admissions as well as existing patients for evidence of infections; if an infection is identified, determine if it is community acquired (prior to admission to your program) or nosocomial
Begin a line listing of each infection so it can be tracked from start to finish, including the organism causing the infection, the sensitivity report, the treatment used, and the date of resolution
Identify patterns of infections that may indicate they may be spread by the facility or staff; such patterns may include several patients on a unit having the same source organism with the same antibiotic sensitivity report indicating they shared the same source, or a geographical distribution pattern of an infection that may indicate the spread by poor handwashing
Follow state and local health department requirements regarding reporting of infections
Educate staff with information gained through above steps as to how they can prevent the spread of infections in your particular setting
Following these steps will help ensure that your patients and staff are protected from unnecessary infections, and that you will enjoy higher success with your clinical outcomes.
Emergency preparedness in nursing homes and other health care agencies increasingly involves the risk of naturally occuring epidemics of infections, or bioterrorism. Examples of this include the need to protect elderly residents from the risk of West Nile Disease when they spend time outdoors. And in the event of bioterrorism, it will be critical that health care providers be alert to the early onset of illnesses and report them to appropriate authorities in order to avoid a larger event.
Nursing home clinical leaders should keep familiar with current issues of infection control. One way to do so is by reviewing each week's issue of the CDC's MMWR. This publication includes information on recent outbreaks throughout the country, and includes guidelines for infection control, immunization procedures, etc. To review the latest issue, click on MMWR .
Safe Lifting and Movement of Nursing Home Residents: The Centers for Disease Control and the National Institute for Occupational Safety and Health (NIOSH) released a document on safe lifting and movement of nursing home residents. The research that the guide is based on shows that safe lifting programs incorporating mechanical lifting equipment can protect workers from injury, reduce workman's compensation costs, and improve the quality of resident care. The document is available by clicking on the PDF icon to the right. 04-22-2006
