Healthcare Hygiene magazine May 2023 May 2023 | Page 23

long-term care infection prevention

long-term care infection prevention

By Buffy Lloyd-Krejci , DrPH , MS , CIC , LTC-CIP

Staying on Top of the Latest Enhanced Barrier Precautions Recommendations for Long-term Care Facilities

There is no question that the COVID-19 global pandemic shook the long-term care industry . It may appear as though SARS-CoV-2 is the only virus that we are fighting . There are , however , ongoing devastating consequences from other infectious diseases such as multidrug-resistant organisms ( MDROs ). In fact , certain MDROs such as Candida auris ( C . auris ) have been showing up in the news quite a lot lately .
A robust infection prevention and control program includes implementing evidence-based research as provided by our public health leaders such as the Centers for Disease Control and Prevention ( CDC ). One such practice is using enhanced barrier precautions ( EBP ). This guidance has evolved over the years with the first interim guidance on July 26 , 2019 , recommending additional personal protective equipment ( PPE ) along with eliminating room restriction for preventing the transmission of novel or targeted MDROs . 1 On July 2021 , the CDC further published the Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities . 3 This “ consideration ” including implementing gown and glove usage for high contact resident care activities for residents that had a wound , indwelling medical device ( regardless of if they have an MDRO colonization ), infection , or MDRO colonization . Finally , on July 12 , 2022 , the CDC published updated guidance for the Implementation of this practice . 3
There has been a lot of resistance regarding the recommendations to implement this higher level of protection for residents with the two most highly voiced concerns being that it will require an exorbitant amount of PPE and that by implementing this practice , it takes away from the homelike environment for the residents .
Before we dive in , I do want to touch on how antimicrobial resistance is an urgent , global threat . Data suggests that antibiotics may be inappropriately prescribed as much as 50 percent of the time . 4 The organisms that we are fighting have evolved to become resistant to antibiotics and contribute to 2.8 million antimicrobial-infections in the U . S . each year . 5 In 2019 , they contributed to 5 million deaths globally . So , what does this have to do with EBP ?
New research demonstrates that the incidence of MDROs within long-term care may be significantly more than is documented . One study looked at residents that were documented with an MDRO and after prevalence testing , uncovered an additional 40 percent of colonized residents . 6 This means that these infections are silently spreading within this healthcare setting .
Another study from the Chicago Department of Health evaluated a nursing home for the prevalence of C . auris , an emerging fungus that causes serious wound , bloodstream , respiratory , and urinary infections . Originally , one resident of 69 ( 1.4 percent ) had a documented case of C . auris . When further prevalence testing was done , the cases of C . auris jumped to 29 ( 42.0 percent ) of the residents having C . auris . 7
These studies raise the issue of basing our prevention practices merely on documented cases . Taking this a step further , it is not appropriate to test every resident for MDROs , therefore , we must take other preventative measures . This brings us to the importance of implementing EBPs for residents who may be at high risk .
Therefore , how do we implement these new practices ? The first
thing I suggest is filling out the CDC ’ s questionnaire to determine readiness ( see link below ). 8 This tool will assist the long-term care facility assess readiness for implementing EBP .
Next , if a facility has a resident that is high-risk ( indwelling device such as a catheter , an IV , a peg tube , a ventilator , colonized with an MDRO , have a wound , or an infection when contact precautions are not required ) they need to wear a gown and gloves when performing a high contact touch activities such bathing , dressing , or transferring the resident .
When a resident is on EBP , ensure there is an appropriate sign on the outside of the door ( see below for a sample ) 9 . This is key to alerting the staff on who to utilize EBP for . Remember that residents do not have to be in a single room or stay confined to their room . Residents can even have a roommate on EBP . Simply remember not to share any PPE . Gowns and gloves are for single use only .
To keep the environment more homelike , consider placing the gown and gloves inside of the resident ’ s room . This is perfectly acceptable , however , if you feel that this will confuse the staff regarding donning procedures for contact precautions ( prior to entering the room ), then consider placing a larger PPE bin in the hallway near the resident ’ s room .
I cannot emphasize enough how important it is to provide ongoing education to the healthcare workers . This practice is very different than contact precautions where PPE needs to be done prior to stepping foot in the resident ’ s room every time . EBP isn ’ t as restrictive for the residents or the healthcare workers .
The success of your facility ’ s ability to prevent the spread of these MDROs requires a multi-layered approach which includes appropriate communication , conducting hand hygiene audits , environmental cleaning audits , and implementing EBP . Keeping our residents and healthcare workers safe from harms and deaths due to infection is no easy task , but putting in the work , the education , and the training will have monumental positive effects immediately and , in the future , as we strive to be proud of our industry and the care it can deliver .
Buffy Lloyd-Krejci , DrPH , CIC , LTC-CIP , is a leading authority on infection prevention in the long-term care industry . Her firm , IPCWell , delivers in-person gap analysis , training , and support to nursing homes across the country .
References :
1 . Implementation of Personal Protective Equipment ( PPE ) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms ( MDROs ) | HAI | CDC
2 . Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities
( cdc . gov ) 3 . https :// www . cdc . gov / hai / containment / PPE-Nursing-Homes . html 4 . https :// www . cdc . gov / antibiotic-use / data / outpatient-prescribing / index . html #:~: text = CDC % 20estimates % 20that % 20at % 20least % 2030 % 25 % 20of % 20 antibiotics , of % 20all % 20outpatient % 20antibiotic % 20use .% 203 % 2C % 204 % 2C % 205 5 . https :// www . cdc . gov / drugresistance / about . html 6 . High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing
Homes : An “ Iceberg Effect ” - PubMed ( nih . gov )
7 . Regional Emergence of Candida auris in Chicago and Lessons Learned From Intensive Follow-up at 1 Ventilator-Capable Skilled Nursing Facility | Clinical Infectious Diseases | Oxford Academic ( oup . com ) 8 . Pre-Implementation Tool — Enhanced Barrier Precautions ( EBP ) ( cdc . gov ) 9 . enhanced barrier precautions final rev3 ( cdc . gov ) www . healthcarehygienemagazine . com • may 2023
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