Long-Term Care Survey Alert

Make infection control a priority.

Starting this summer, expect surveyors to take a closer look than usual at F-441 (infection control) and F-315 (urinary incontinence). That’s because a new report from the U.S. Department of Health and Human Services (HHS) is revving up the federal government’s effort to prevent healthcare-acquired infections (HAIs) in long-term care facilities.

The report, Phase III of the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination, focuses exclusively on long-term care facilities. Released in April, the report states that the most commonly reported HAIs in nursing homes/skilled nursing facilities (NH/SNFs) are urinary tract infections, lower respiratory tract infections, skin and soft tissue infections, and gastroenteritis. (The report noted that no recent data was available concerning the prevalence of central-line-associated blood stream infections (CLABSIs) in nursing homes.)

By the numbers: The 1.5 million adults living in nursing homes/skilled nursing facilities are affected by 765,000 to 2.8 million HAI infections annually, according to the Action Plan. For providers, those numbers stand to have a big impact on quality of care, avoidable hospital readmissions — and survey results.

Reality check: While it is a great time to rein in HAIs, as you gear up make sure you set goals you can attain. A recent study suggests that HAIs may not yet be 100 percent preventable even with strict implementation of current evidence-based prevention strategies. The study, published in 2011 in the journal Infection Control and Epidemiology, suggests that current known risk-reduction strategies can prevent 65 to 75 percent of central line-associated bloodstream infections and catheter-associated urinary tract infections, according to lead author Craig A. Umscheid, MD, a physician and director, for the Center for Evidence-based Practice at the Hospital of the University of Pennsylvania in Philadelphia.

Still, efforts to adhere to guidelines are well worth it — and data suggests that most nursing homes have gains to make. Evidence-based prevention strategies make possible the potential to save “thousands of lives and billions of dollars,” Umscheid and his colleagues remind providers.

Focus: The HHS Action Plan addresses a number of types of HAIs, but it spotlights prevention on the two essential fronts: UTIs and Clostridium difficile infection (CDIs). For tips on UTI prevention, read on. For advice on contending with CDIs, see next month’s Long Term Care Survey Alert.

Review These UTI Basics

Unfortunately, it is not uncommon for providers to take a wrong turn early on the road to compliance—by failing to make a proper diagnosis, experts say.

Make sure your caregivers know the fundamentals when it comes to differentiating symptomatic UTIs from asymptomatic bacteriuria, coaches Robert M. Palmer, MD, MPH, of The Glennan Center of Geriatrics and Gerontology in Norfolk, Virginia, an expert who has helped the Virginia Department of Health hone its new UTI prevention tool kit (see Resources for more information).

Asymptomatic bacteriuria is the presence of bacteria in the urine, but absent symptoms — and survey compliance depends on your staff being skilled at differentiating between it and a symptomatic UTI. Include in staff training a review of CMS’s F-315 guidance itself. Although that guidance is based on diagnostic criteria from the widely recognized study by McGeer et al, the survey guidance is subtly different — and misconceptions by frontline staff can come back to haunt you, cautions Edna D. Garcia, BSN, RN-BC, director of clinical education at Riverside Lifelong Health and Aging Related Services in Newport News, Virginia. (For a review, see “Cheat Sheet: Here’s How to Identify a Symptomatic UTI”).

Red flags. On the prevention front, it is also essential that your clinicians be proficient at assessing factors that affect urinary tract infection risk. In addition to the all-important task of identifying unnecessary catheter use, caregivers should know that dementia, mobility limitations, and immunity impairments can all put residents at increased UTI risk.

Study the Evidence

As you rethink your facility’s approach to preventing and treating UTIs, consider the following evidence-based tips:

There is currently no solid evidence that elderly nursing home residents will benefit from cranberry supplementation; still, cranberry can’t hurt, says Garcia. A recent small study testing the effect of once or twice daily cranberry supplements (1,650mg cranberry capsule) did not show a protective effect from supplementation, but the study did suggest that there are no safety concerns. Until larger studies offer conclusive evidence that cranberry has no impact in the elderly, some facilities continue to include it in their preventive arsenal.

When catheters can’t be avoided, be sure your staff consistently employs best practices. Maintaining aseptic technique and positioning the collection bag low to avoid reflux are vital safeguards. Furthermore, guidelines recommend replacing a catheter prior to commencing antibiotic therapy in a symptomatic catheterized patient if the catheter has been in place for longer than one week.

Get Creative

A commitment to diligent continence care will help your facility keep UTIs at bay. In order to flush out bacteria, after all, it is vital that residents stay well hydrated, reminds Garcia. To make sure all disciplines participate in the effort, get creative, she advises.

A few ideas to get you started:

• Fluid rounds. A cart stocked with water and other healthy beverages will make it easy and appealing for residents to stay hydrated. It’s also a great way for staff to engage with residents in a positive way.
• Hydration happy hour. Some facilities offer regular “happy hours” designed to help residents rehydrate — and socialize — with “cocktails.”(Little Hawaiian umbrellas, anyone?) Lemonade, icy coolers filled with drinks, and frozen juice pops are other ways to spread cheer and proper hydration.
• Tea time. This is another take on a hydrating social hour, but steer clear of caffeinated beverages.

A related idea: Make it standard practice to offer residents and their guests beverages during visits.

Although it can be constructive to have fun with hydration, don’t neglect the basics. Regular resident and staff education about maintaining proper hydration — at least annually — is also important.

IT Tip: Use information technology to bolster your efforts to fight infection. If you are like most nursing homes, there is probably room to improve. The HHS Action Plan cites a recent study from Utah that suggests nursing homes fail to use technology to their full advantage for Infection Control Programs. Specifically, the researchers found that 25 percent of facilities had outdated systems, and fewer than 20 percent had “fully integrated radiology, diagnostic laboratory, or microbiology data with their facility computer systems.”

“IT tools [are] largely underutilized for implementing the ICP program,” the report concludes.

The QA connection: As of this year, all nursing homes must have Quality Assessment and Performance Improvement (QAPI) program in place. The HAI Action Plan plugs making the prevention of HAIs an “excellent goal” for your initial QAPI project. In addition to improving resident outcomes and reducing costs, HAI prevention would help facilities by providing an “external surveillance system to monitor and analyze data on the incidence of HAIs in their facility,” providing baseline data to measure the effectiveness of prevention initiatives.