A great deal of information has been published concerning HAIs infections in the long-term-care facility (LTCF). However, application of hospital infection control guidelines to the LTCF is often unrealistic in view of the differences between the acute settings in hospitals and the LTCF and the different infection control resources. It could be argued that while the Infection Control Program (ICP) is well established at Mater Dei Hospital the situation in SVPR is of inadequate standard. Standards and guidelines specific to the LTCF setting are not currently available in Malta. Since the numbers of HAI’s are several, in this assignment only the most important recommendations and strategies are discussed that apply to the clinical practice at SVPR.
Infection Control Program
Infection control programs (ICP) are among the first organized efforts to improve the quality of healthcare delivered to patients (Nicolle, 2000; Pittet, 2005). A number of authors have discussed the component of infection control program in LTCF (Goldrick, 1999, Nicolle, 2000). However, there are many limitations that affect the type and extent of programs developed. Most authors feel that an infection control program should include some surveillance for infections, an epidemic control program, education of infection control methods, policy and procedure formation and review, an employee health program, a resident health program, and monitoring of resident care practices. The program must also cover environmental review, antibiotic monitoring, product review, and reporting of disease to public health authorities (Goldrick, 1999; Friedman, 1999).
There are three principal goals for healthcare infection control programs regardless of the setting; to protect the patient/resident, to protect the healthcare worker- workers, visitors and others in the facility and to accomplish the previous goals in a timely, efficient, and cost-effective manner, whenever possible. Achieving these goals is the driving force behind every recommendation and action of the infection control program (Friedman, 1999).
It is critically important that there is sufficient infection control nurses provided in all hospitals. It has been shown that a ratio of 1 full time infection control nurse per 250 hospital beds is necessary for full efficacy (Strausbaurgh & Joseph, 2000). However, the current situation in SVPR is that one infection control nurse has the responsibility to cater for the 1200 residents. Hence, more full time infection control nurses are needed. Therefore it is suggested that a more active, effective, facility wide infection control program should be established to help prevent the development and spread of infectious diseases in SVPR.
Education and training
The value of education of the LTCF ICP has long been recognised, and surveys confirm this need (Smith et al., 1992). It has been also discussed that one of the most important roles of the ICP is education of personnel in basic infection control principles. It is recommended that the ICP routinely assess the educational needs of staff, residents, and families and develop educational objectives and strategies to meet those needs; collaborate in the development, delivery, and evaluation of educational programs or tools that relate to infection prevention, control, and epidemiology; and continuously evaluate the effectiveness of educational programs and learner outcomes. Education should focus on new personnel and certified nursing assistants (Smith et al., 1992). In addition, all individuals with direct resident care responsibility need education in early problem and symptom recognition. The teaching methods used need to be sensitive to language, cultural background, and educational level. A coordinated, effective educational program will result in improved infection control activities (Leinbach & English 1995). Moreover, each facility should document such training.
Guidelines and policies
An important aspect of infection control programs is the development of guidelines and the updating of infection control policies and procedures. Guidelines should be evidence based. It is not sufficient for a hospital to have detailed policies and procedures governing infection control; it must also take steps to determine whether the staff adheres to these policies and guidelines in practice. Practices most frequently don’t correspond to recommended guidelines. It is important that designed strategies including educational- based programs aim at better compliance to infection control. Adherence to guidelines is essential in order to be able to interpret infection rates, target interventions in order to reduce HAI and improve patient safety and quality of care.
The compliance to these guidelines should be monitored with feedback given to the relevant clinical areas. These guidelines should be updated on a regular basis to include new scientific findings and also taking into account local practicality and cost. The updated guidelines should be freely available in the relevant clinical areas. Goldrick, 1999 have found infection control in LTCFs to be less than adequate. Goodman and Solomon cited by Friedman (1999) reported in their review that most of the outbreaks were associated with non-adherence to infection control procedures.
Hand Hygiene The single most effective way of combating HAIs is to improve hygiene in health settings especially hand hygiene (CDC, 2003). Hand hygiene involves the use of an alcohol based hand rub, washing with soap and water and the use of protective hand gloves (Thompson et al, 1997). According to the CDC, the single most important thing a person can do to keep from getting sick and spreading illness to others, protect patient safety, and reduce infection, is to keep hands clean by thorough hand washing (CDC, 1992).
SVPR has guidelines on hand hygiene which includes Hand washing, glove usage and the bare below elbow policy. The policy details specific indications for hand hygiene, including when coming on duty; whenever hands are soiled; after personal use of toilet; after blowing or wiping nose; after contact with resident blood or body secretions; before performing any invasive procedures on a resident; after leaving an isolation room; after handling items such as dressings, bedpans, catheters, or urinals; after removing gloves; before eating; and on completion of duty. Hand hygiene compliance should be monitored.
Poor compliance with hand hygiene recommendations has been noted in LTCFs, as in other settings (Thompson et al, 1997; CDC, 1992). For effective compliance audits are necessary. Non- compliance with hand hygiene is a well-known challenge and future studies should aim at studying compliance with hand hygiene procedures in LTCFs. Laminated cards, posters, slide sets, and fact sheets can be used in a health care setting to promote recognition and utilization.
Alcohol-based hand rubs should be made available and used by staff, especially when hand washing facilities are inadequate or inaccessible. A positive aspect at SVPR is that a hand rub is available at each bed and near each hand wash basin. Residents and relatives make use of the hand rubs available.
Fingernails and Artificial Nails
Artificial nails are more likely than natural nails to harbor pathogens that can lead to health care acquired infections (CDC,2003 ). In the year 2008, a protocol for Fingernails and Artificial Nails was implemented and staff at SVPR had to adhere to the recommended guidelines. Artificial nails and nail tips are prohibited for all health care workers and providers who provide direct, “hands-on” patient care. However, though nurses adhere to this policy, care workers are often seen with artificial nails while caring for elderly patients. It is necessary that more reinforcement and auditing be held in wards. It is up to each health care worker, to become a model of prevention. This includes not wearing artificial nails, keeping nails trimmed and neat and washing hands when necessary.
Prevention of UTI This is was thinking to omit …??? Guidelines for prevention of catheter-associated UTIs in hospitalized patients are generally applicable to catheterized residents in LTCFs. Recommended measures include limiting use of catheters, insertion of catheters aseptically by trained personnel, use of as small diameter a catheter as possible, hand washing before and after catheter manipulation, maintenance of a closed catheter system, avoiding irrigation unless the catheter is obstructed, keeping the collecting bag below the bladder, and maintaining good hydration in residents.
Prevention of antibiotic-resistant organisms Antibiotic- resistant bacteria pose a significant hazard, and this resistance has been strongly associated with antibiotic use. Antimicrobials account for approximately 40% of all systemic drugs prescribed in LTCFs with a likelihood of 50% to 70% that a resident will receive at least one course of a systemic antimicrobial agent during a 1-year period (Nicolle et al., 2000). LTFC should have clear policies and practices to ensure that patients are not started on antibiotics without a credible clinical picture. The CDC has published a 12 step program for preventing anti microbial resistance among LTCF resididents that addresses the broad areas of preevnting infections, diagnosis/ treatment of infection, using antibiotics widely, and preventing transmisison(CDC, 2002).
Authors of evidence-based guidelines on the increasing occurrence of multidrug-resistant organisms propose these interventions: stewardship of antimicrobial use, an active system of surveillance for patients with antimicrobial-resistant organisms, and an efficient infection control program to minimize secondary spread of resistance (Goldmann et al., 1996; CDC, 2008). Antimicrobial stewardship includes not only limiting the use of inappropriate agents, but also selecting the appropriate antibiotic, dosage, and duration of therapy to achieve optimal efficacy in managing infections. Other measures to prevent antimicrobial resistance include steps to (1) employ programs to prevent infections, (2) use strategies to diagnose and treat infections effectively, (3) operate and evaluate antimicrobial use guidelines (stop orders, restrictions, and criteria-based clinical practice guidelines), and (4) ensure infection control practices to reduce the likelihood of transmission (CDC,2008)
Nurses have a vital role in managing antibiotic resistance by ensuring that everyone who has contact with their patients adheres to appropriate infection control practices. They can also educate patients on the proper use of antibiotic.
Conclusion The costs of HAI are huge and include patient morbidity and mortality, hospital and community medical costs, the impact of blocked beds, and wider socio-economic costs. With the aging population and the increasing role played by LTCFs in healthcare, it is essential to address infection control in these facilities. The costs of infection control programs and staffing are relatively small and with only a small degree of effectiveness they can pay for themselves. Investment in infection control is therefore highly cost effective.