Long-Term Care Survey Alert

The Centers for Disease Control and Prevention is targeting infection control practices that promote antibiotic resistance in long-term care facilities a new campaign that provides a readymade blueprint for regulatory oversight. So its time to get a step ahead of surveyors, experts advise.

The CDCs inpatient initiative includes 12 action steps (see article 7) that include preventive measures, such as vaccinating residents and getting those urinary catheters out.

The campaign also requires clinicians to adopt a new mindset by treating actual infection, not just a positive bacterial culture in the absence of signs and symptoms.

The CDC is also recommending that clinicians routinely order sensitivity testing to guide their treatment decisions when signs of infection are present. "Practitioners should not just consider the microorganism in treating but also its sensitivity" to antibiotics, Denise Cardo, chief of the CDCs prevention and evaluation branch, tells Eli.

Surveyors dont seem to be targeting appropriate use of antibiotics yet. "But its a good idea for the industry to take a proactive approach in this area and put together a plan before the Centers for Medicare & Medicaid Services tells facilities what to do," says James Marx, an infection control specialist with BroadStreet Solutions in San Diego.

Darla Watson, director of clinical informatics for Atlanta-based Mariner Post-Acute Network, agrees. "Whenever there is a change in clinical focus or new information, such as this one by the CDC, you can expect surveyors to begin focusing on that area in the future, as well," she says.

Surveyors may, in fact, one day soon follow a protocol for antibiotic use, just as they do for antipsychotic drugs. "Facilities need to start viewing antibiotics the same way as they do psychotro-pics," Marx cautions. "Antipsychotics used to be prescribed inappropriately in the long-term care facility, but now staff look more closely to see if a resident really requires them," he notes.

To start, facilities should pay special attention to how antibiotics are used in treating respiratory infections and asymptomatic urinary tract infections or UTIs. Marx predicts those two areas, in fact, will be the focus for surveyors in targeting inappropriate antibiotic use.

"There are still nursing facilities that have procedures to culture post-urinary tract infections," says Dennis Stone, a long-term care physician and chief medical officer for HealthEssentials in Louisville, KY. Yet, unless the patient is symptomatic, you dont reculture because you will grow a bug when the resident doesnt really have an infection," he says.

The net result, of course, is the resident gets a second round of unneeded antibiotics, which breeds more resistant microorganisms and exposes the resident to potential adverse effects from the drugs. Antibiotics are also expensive and quickly whittle away a SNFs Medicare prospective payment per diem.

Instead, nursing facilities should be focusing on preventing UTIs from occurring in the first place, or recurring after treatment, by making sure residents get enough fluids. Watson reports seeing survey teams increasingly hone in on a facilitys frequency of UTIs and its hydration program. "Surveyors are doing a much better job of connecting the dots in looking at interrelated issues such as dehydration and rate of urinary tract infection," she tells Eli.

Clinical guidelines also discourage automatic use of antibiotics to treat simple upper respiratory tract infections, especially in the absence of fever. Again, adequate hydration is the key to keeping respiratory secretions thin and preventing complications from simple colds.

Theres also a push for more solid clinical evidence that a patient has pneumonia before resorting to antibiotics for example, an infiltrate on the X-ray, worsening oxygenation and an elevated white blood cell count. Prescribing practices for immunocompromised residents may vary.

Pressure ulcers also provide a temptation for well-meaning facility staff to culture and treat what is really surface contamination, not infection. "If staff just swabs the surface of a wound, then the culture will grow the same organisms found on the skin," Marx says.

The CDC advises diagnosing wound infection by obtaining fluid through needle aspiration or tissue in an ulcer biopsy for culture. Marx, however, recommends long-term care clinicians treat wound infections based on signs and symptoms, as its not practical to perform biopsies or wound aspirates in a facility setting unless staff suspects methicillin-resistantStaphylcoccusaureus(MRSA).

"However, If the patient had a history of MRSA or if the organism were in the facility, then the facility should obtain a biopsied or aspirate sample from the wound for culture and sensitivity," Marx advises.

Of course, some "old school" surveyors trained in the heyday of antibiotics may still expect facilities to give out these medications like candy. So in order to prevent deficiencies for following the CDCs recommendations, facilities should spell out the new guidelines in their infection control policies and procedures, Stone suggests.

"The medical director should reaffirm the new policies and procedures in a letter that is kept on file for surveyors," Stone adds. "And the attending physicians should also [refer to these guidelines] in the medical record as a rationale for their treatment decisions."