Read this article for 1 continuing education (CE) contact hour.

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Faculty: Linda L. Spaulding, RNC, CIC

Method of Participation: Nurses may receive 1 continuing education (CE) credit hour (0.1 CEU) by reading the article on pages 31–35 and completing the post-activity test and evaluation form on page 36. Successful completion entails participants obtaining a score of at least 70% on the post-test. A certificate of completion will be mailed to the address listed on your post-test/evaluation form within 6 weeks of receipt of the documents.

Date of Original Release: January 1, 2007

Expiration Date: December 31, 2007

Accreditation Statement: The North American Center for Continuing Medical Education (NACCME) is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. This continuing nursing education activity was approved by the Pennsylvania State Nurses Association for 1 contact hour (Provider No. 110-3-E-06). Provider approved by the California Board of Registered Nursing, Provider No. 13255, for 1 contact hour.

Disclosure Policy: All faculty participating in continuing education programs sponsored by the North American Center for Continuing Medical Education are expected to disclose to the meeting audience any real or apparent conflict(s) of interest related to the content of their presentation. It is not assumed that these financial interests or affiliations will have an adverse impact on faculty presentations; they are simply noted here to fully inform participants.

Faculty Disclosures: Ms. Spaulding has disclosed that she has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of this article.

Learning Objectives: Upon completion of this educational activity, participants should be able to:
• State what is the second most common cause of infection among residents in long-term care facilities
• List three questions that must be addressed when protecting residents from influenza and pneumococcal pneumonia
• Discuss what the purified protein derivative (PPD) requirements are for long-term care facilities
• Identify diseases and illness that are common in many long-term care facilities.

Target Audience: Nurses

Sponsor: North American Center for Continuing Medical Education (NACCME)

O

ne of the major goals of a long-term care facility is preventing the transmission of infection from workers to residents. Infection concerns in long-term care facilities include endemic infections, such as respiratory tract, urinary tract, skin and soft tissue, and gastrointestinal (GI) infections. This article will review all of these infections to discuss how they can be transmitted from healthcare workers to residents.

Influenza and Pneumococcal Pneumonia

       Nursing home-acquired pneumonia is the second most common cause of infection among residents in long-term care facilities. Its incidence has ranged from 0.3–4.7 infections per 1,000 resident days.¹ When looking at how healthcare workers can transmit respiratory tract infections, a few questions should be asked.
       First, what is the policy of the facility related to employees calling in sick? Is the policy of the facility flexible enough to encourage employees not to report to work if they are sick? There are many factors that play into the employees’ decisions to come to work sick. Some of these factors may include the need to pay their bills, loyalty to the employer, wishing to have perfect attendance, the fear they will get in trouble if they call off sick, and staff shortages. It is up to the employer to reinforce the need for a safe, sick-free environment for residents.
       Second, does the facility provide the influenza vaccine to employees free of charge? It is well documented that influenza A outbreaks in long-term care facilities can result in up to 60% of the residents becoming ill, with 25% of those affected developing complications severe enough to result in hospitalization and death.³ New guidelines from the Centers for Disease Control (CDC) encourage immunizing health care workers against seasonal influenza. This year the CDC recommends for healthcare workers to sign a refusal form if they do not want the influenza vaccine.

Table 1

       Despite the proven benefits of vaccinating healthcare workers on resident outcomes and employee absenteeism, vaccination coverage among healthcare workers remains as low as 40%. Many long-term care facilities do not provide the flu vaccine to employees or residents. It must be mentioned that healthcare workers 65 years of age and above and those who have underlying chronic medical conditions should be encouraged to obtain the pneumococcal vaccine. Increasing the vaccination rates among healthcare workers is vital to protect residents and reduce healthcare cost.
       Pneumococcal disease accounts for more deaths than any other vaccine-preventable bacterial disease. Case fatality rates from pneumococcal bacteremia can be as high as 40% among elders.⁴ The bacterium Streptococcus pneumoniae (S. pneumoniae) accounted for an estimated 106,000–175,000 cases of pneumococcal pneumonia in the United States, of which 31,479 required hospitalization.⁵ Pneumococcal infections have been estimated to result in 12,500 deaths each year in the United States.⁵
The proposed public health target is to achieve a 90% vaccination rate for both influenza and pneumococcal infection by 2010. The Centers for Medicare & Medicaid Services (CMS) published a final rule requiring Medicare- and Medicaid-participating nursing homes to provide residents with the opportunity to be immunized against influenza and pneumococcal infection. The new regulation, which will be codified as 42 CFR 483.25(n) “Quality of Care,” complements the existing federal requirement at 42 CFR §483.65(a), “Infection Control,” which requires facilities to have an infection control program that is effective for investigating, controlling, and preventing infections. The facility must meet various criteria (see Table 1).
       Remember, too, that other respiratory infections, such as parainfluenza and respiratory syncytial viruses (RSV), can be transmitted from healthcare workers to residents.

Tuberculosis

       The Occupational Safety and Health Administration (OSHA) requires all healthcare facilities to have a Tuberculosis Exposure Control Plan. This plan should be designed to decrease the possibility of tuberculosis (TB) being transmitted from healthcare workers to residents and vice versa. Healthcare workers are required to have a two-step positive purified protein derivative (PPD) at the time of hire unless they can provide documentation of a negative PPD in the past 12 months. Annual PPDs should be given thereafter. This prevents healthcare workers who have active, infectious TB from working around residents. All employees with a history of a positive PPD test should have annual and ongoing screen for signs and symptoms of TB. Should an employee exhibit a TB symptom anytime during the year, he or she should be required to have a chest X-ray and work up for possible TB. All employees who convert from a negative PPD to a positive PPD should immediately be worked up for possible infectious TB; this may include a chest X-ray, sputum samples, and evaluation for possible chemotherapy. Finding a resident who has either converted to a positive PPD or has active, infectious TB may lead a facility to find an employee with active, infectious TB.

Urinary Tract Infections

       When looking at staff transmission of infection and its relationship with urinary tract infection (UTI), one must look at nursing competency as it relates to insertion of Foley catheters. Inappropriate insertions of a Foley catheter can lead to not only a UTI but urosepsis and death among the elderly. Foley catheters should be inserted using sterile technique. Use of a closed Foley catheter system is also another recommendation to prevent UTIs related to Foley catheters.
       The most effective way to avoid a UTI associated with Foley catheters is to either not use them or limit their use to short periods. If Foley catheters are used, ensuring an adequate urinary drainage or using systems with backflow valves can help to decrease the incidence of UTIs from urine flowing back up the tubing and into the resident’s bladder.

Methicillin-Resistant Staphylococcus Aureus

       Employees who come to work with skin infections, including draining boils, open infected wounds, and rashes like scabies, can become a source of infection transmission to residents. In areas of the United States with high incidence of methicillin-resistant Staphylococcus aureus (MRSA), staff members have been found to have boils that may or may not have been treated by their personal physicians.
       These employees may hide this area with a dressing or with their uniforms, and employers may not know until there is an outbreak of residents with boils caused by MRSA. It is possible for the employee to become infected with MRSA from a resident, after which he or she can become the route of transmission to other unsuspecting residents and employees.
       With the dramatic rise of community-acquired MRSA, long-term care facilities need to monitor staff more than ever for infected wounds that may at first appear to be bug bites. If these areas become infected, check for MRSA.

Scabies

       Over the past several years, infestation of scabies has been epidemic and estimated to affect millions of persons worldwide. Most notably, outbreaks occur in confined areas (eg, nursing homes). Scabies is highly infectious and transmitted by contact with either an infected person or contaminated linens, clothing, or other cloth items.
       Scabies is caused by a mite called sarcoptes scabiei var hominis. There are variations of scabies that affect animals as well as humans. The female scabies mite burrows into the layers of the skin to lay her eggs. Meanwhile, the mites produce packets of feces known as scybala, which, in addition to the mites, produce intense itching.
       An employee is often infected from his or her children if their school has an outbreak. The employee can bring scabies into the facility and infect many residents before anyone realizes they have scabies. When employees go to their doctors complaining of a rash, they are often told they have contact dermatitis. With that diagnosis the employee returns to work and is able to transmit scabies to the residents he or she comes into contact with. This is the start of a facility-wide scabies outbreak.
       Policies should specify treatment of infected individuals as well as asymptomatic, close contacts. Linens and other shared items need to be laundered or disinfected at specific times and/or temperatures. The incubation period for scabies mites ranges from 2–6 weeks before itching occurs in persons not previously infected. In persons who have previously been exposed to scabies, the incubation period is 1–4 days.⁶

Gastrointestinal Infections

       Norovirus (previously known as Norwalk virus) and Clostridium difficile (C. difficile) are among the types of GI infections that can be transmitted from employees to residents and vice versa. Norovirus has often been in the news. The outbreaks of GI on cruise ships have been linked to the norovirus. Many nursing home outbreaks attributed to Norwalk virus have occurred over the past 5–6 years. Noroviruses can be transmitted via food or water or person to-person through contamination by infected feces and vomit. There are many strains, so it is difficult for a person to build immunity to the virus. Symptoms of the norovirus include nausea, vomiting, diarrhea and abdominal pain, headache, and low-grade fever. Food can be contaminated either by direct contact with contaminated hands or work surfaces that are contaminated with stool or vomit. Tiny droplets from nearby vomit can also travel through the air and contaminate food.
       Like norovirus, C. difficile can be transmitted on the hands of healthcare workers or from environmental contamination to susceptible residents. Preventing the spread of infections from healthcare workers to residents in long-term care facilities takes a well-developed infection control program. Steps to prevent this transmission include:
• Having well-written policies and procedures for surveillance of infections to ensure early identification of problems
• Making sure that all staff immunizations (eg, those for measles, mumps, rubella, varicella, influenza, pneumococcal diseases, and hepatitis B) are up to date
• Monitoring and enforcing staff hand washing in conjunction with staff education
• Educating and monitoring staff on how infections are transmitted
• Establishing competencies for Foley catheter insertions, wound care, and dressing changes
• Monitoring staff for illnesses and rashes on an ongoing basis
• Monitoring staff with respiratory tract infections continuously for possible flu, TB, and other respiratory illnesses that may be circulating.
       Most important, however, is to not allow staff members to work when they are ill or have infections lesions.

References

1. Strausbaugh LJ, Joseph CJ. Epidemiology and prevention of infections in residents of long term care facilities. In: Mayhall CG, ed. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:1461–1482.
2. Centers for Medicare & Medicaid Services (CMS). Nursing Home Immunization Requirement, Ref: S&C-06-03 (rev). November 17, 2005. Available at www.ctachca.org/documents/HotTopics/
051114CMStoStateSurvey
AgenciesreImmunizations.pdf. Accessed January 3, 2007.
3. Arden NH, Patriarca PA, Kendal AP. Experiences in the use and efficacy of inactivated influenza vaccine in nursing homes. In: Kendal AP, Patriarca PA, eds. Options for the Control of Influenza. New York, NY: Alan R. Liss, Inc.; 1986:155–168.
4. Quick RE, Hoge CW, Hamilton DJ, et al. Underutilization of pneumococcal vaccine in nursing homes in Washington State: report of a serotype-specific outbreak and a survey. Am J Med. 1993;94:149–152.
5. Gardner P, Schaffner W. Immunization of adults. N Engl J Med. 1993;328:1252–1258.
6. Sciammarella J. Scabies. Available at www.emedicine.com/
emergtopic517.htm. Accessed January 3, 2007.