Long-Term Care Survey Alert

Disinfection is the battle cry in the war on c. difficile.

A few years have passed since the Centers for Medicare and Medicaid Services (CMS) issued its red-letter correction on clostridium difficile infections (CDIs) in nursing homes, but with this year’s renewed focus on F-441 (infection control), experts suggest that you spend some time with that 2009 survey guidance.

In particular, CMS’s Transmittal 55 (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r55soma.pdf ) highlighted a few truths about C. difficile that are still essential to any nursing home striving to bring down healthcare acquired infections (HAIs) related to the intractable pathogen:

“The C. difficile can survive in the environment (e.g., on floors, bed rails or around toilet seats) in its spore form for up to 6 months,” warned the agency in red type. “Rigorously cleaning the environment removes C. difficile spores, and can help prevent transmission of the organism. Cleaning equipment used for residents with C. difficile with a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach) will also reduce the spread of the organism. Once mixed, the solution is effective for 24 hours.”

Keep this mantra in mind: Like the real-estate agent’s adage about the importance of “location, location, location,” CMS is intent on reminding surveyors and providers alike that when it comes to C. difficile, succeeding is largely about “disinfection, disinfection, disinfection.” Take to heart the feds’ call to “rigorously clean” at the first sign of a C. difficile outbreak — and you are sure to fare far better come survey time.

Background: Surveyors’ interest in infection control in the coming months is likely to be fueled by a report released in April by the U.S. Department of Health and Human Services (HHS). The report, Phase III of the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination, focuses exclusively on preventing HAI’s in long-term care facilities. The report, in particular, calls for renewed focus on preventing urinary tract infections (see the June issue of Long Term Care Survey Alert) and C. difficile infections.

Experts agree that any attempt to bring down CDI rates depends in large part on teamwork between clinicians, caregivers, and environmental service workers.

Because C. difficile is shed in feces, any surface or material that becomes contaminated with faces could serve as a breeding ground for C. diff spores. That includes commodes, bathing tubs, and rectal thermometers, cautions educational material issued by the Centers for Disease Control and Prevention.

Don’t miss: When it comes to preventing transmission through cleaning and disinfection, it is especially important not to miss items likely to be contaminated with feces — as well as surfaces that are touched frequently.

The need to clean applies equally to human hands. In fact, the main mode of transfer of spores from one affected patient to another is the hand of a caregiver who may have touched a contaminated surface or item.

Special Focus Area 1 — Environmental Services

To take stock of your C. diff. defenses, first check on the commitment and understanding of a facility’s environmental services department — both the managers and frontline staff, urges Emily Lutterloh, MD, MPH, a physician and trainer with the Bureau of Healthcare Associated Infections, New York State Department of Health in Albany, New York. It is essential that environmental services personnel, including frontline staff, understand their important role in preventing serious, potentially fatal, infection, stresses Lutterloh.

Do this: Check your protocols against the most current guidelines (see “Resources,” p. 60), and then put in place a monitoring program that allows you to assess how well workers carry out procedures for cleaning and disinfection.

For example, a surface that’s not “cleaned” (a process that removes foreign material such as soil and organic materials) cannot be effectively “disinfected” (the process by which the number of pathogenic microorganisms are reduced).

Be sure you monitor disinfection effectively. Some nursing homes find that the most successful way to monitor environmental services’ efforts is with fluoroscopy, reports Lutterloh.

How it works: A fluorescent powder or gel is placed on surfaces in rooms to be cleaned, and this marker is then used as a proxy to see if and how well a surface was cleaned. If the frontline staff rids the surface of all traces of the marker (as tested post-cleaning/disinfecting using fluoroscopy), then the cleaning staff is doing a good job.

Non-punitive feedback for environmental services managers and workers is important, says Lutterloh. “Engage them,” she encourages. Give the frontline staff the information and feedback they need to do a good job.

Tripping point: Standard EPA-registered hospital disinfectants are not effective against C. difficile spores.

Special Focus Area 2 — Hand Hygiene

Hand hygiene is another pillar supporting infection control — especially given C. difficile’s spore-spreading status.

In a non-outbreak situation, the use of alcohol-based hand rubs are acceptable, according to current guidelines. But in an outbreak, the standard becomes hand washing with soap and water after caring for patients with CDIs, explains Erik R. Dubberke, MD, of the Washington University School of Medicine in St. Louis, Missouri.

Gloves and gowns are also an essential precaution, to control the spread of spores.

Why it’s important: Research to date suggests that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.

Education is key. Refresh hand hygiene training for frontline caregivers often — and be sure that your facility is effectively monitoring and reporting staff adherence to hand hygiene practices. You may also want to consider a standardized approach or program for resident and visitor hand hygiene.

To control C. difficile infection, pay special attention to proper training on how to remove gloves, urges Lutterloh, focusing on the goal of not contaminating hands during the process of removal. In addition, hands should be washed after properly disposing of the gloves.

Review Isolation Policy, Antibiotic Use

Optimize isolation protocols. Ideally, a resident with proven CDI should be placed in a private room. If that’s not possible, consider “co-horting,” the practice of placing two residents with CDIs in the same room. If a resident with C. difficile must be in a room with an uninfected resident, observe standard precautions such as using a privacy curtain and maintaining at least a distance of three to four feet between residents. If a bathroom must be shared, consider asking the uninfected resident to use a bedside commode until the infection is cleared, for protection against spores likely to be present in the bathroom prior to disinfection.

Use antibiotics judiciously. Strong evidence supports the notion that increased exposure to antibiotics exacerbates the problem of antibiotic resistant — for C. difficile and other bacteria. In fact, the CDC calls attention to antibiotic resistance as “one of the world’s most pressing public health problems,” and infection control experts suggest that all healthcare facilities should have in place a formal antimicrobial stewardship program.

A new F-tag? Given the feds’ attention to the problem of antibiotic resistance, antimicrobial stewardship could become a new survey focus for nursing homes, some long-term care consultants say. Stay ahead of the game by ramping up your efforts now.

Keep it up: Continue outbreak-level precautions until a resident’s CDI-related diarrhea ceases. In addition, guidelines advise isolation for several days beyond symptom resolution. That’s because some residents with CDIs continue to shed the microorganism for several days following cessation of diarrhea.