Infection Control Practices in Assisted Living Communities

Article Outline

• Abstract
• Risk of Infection among Older Adults
• Presentation of Infection
• Definitions Related to Infection Control
• Pneumonia
• Influenza
• Tuberculosis
  • MRSA
  • C. difficile
• Common Infection Control Practices
  • Education
  • Standard Precautions
  • Transmission-based Precautions
• H1N1 Influenza
  • Flu Pandemic
  • Pandemic Safety Index (PSI)
  • H1N1 Vaccine
  • Health Care Workers and ALC Staff Protection
  • Role of the Assisted Living Nurse in H1N1 Influenza Management
• References
• Biography
• Copyright

Few states require assisted living communities (ALCs) to have an infection control plan (ICP), nor do they provide guidelines about infection control practices in ALCs or require communicable disease reporting to appropriate health agencies or even within the community itself. Most communities do not have an ICP that addresses prevention, detection, investigation, control, monitoring, or communication of an infectious outbreak. This article discusses the presentation and management of pneumonia, influenza, tuberculosis, methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile infection; describes common (i.e., standard) infection control practices in long-term care; and provides the most recent information and recommendations from the Centers for Disease Control and other sources regarding prevention and treatment of the H1N1 viral influenza. The key to prevention is education and appropriate handwashing and respiratory hygiene practices. Internet sources for up-to-date information are also provided.

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• Ethel Mitty

Few states require assisted living communities (ALCs) to have an infection control plan (ICP), provide guidelines about infection control practices, or require communicable disease reporting. Some states' assisted living regulations have admission criteria regarding tuberculosis and HIV/AIDS. An ICP is a form of risk management in that it contains procedures to prevent, detect, investigate, control, and monitor an infectious outbreak. It also includes communication (reporting) requirements within the community and to the local health department, as appropriate.¹ Given the absence of ICPs in many communities, this article about infection control issues in ALCs begins with a brief review of the presentation of infection in the older adult. It specifically describes and discusses the presentation and management of pneumonia, influenza, tuberculosis, methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile infection. Next, a description of common (i.e., standard) infection control practices in long-term care, drawn from the Centers for Medicare and Medicaid Services (CMS) infection control manual (i.e., F tag 441), is provided. The article concludes with the most recent information and recommendations from the Centers for Disease Control (CDC) and other sources regarding prevention and treatment of H1N1 viral influenza, originally and erroneously called swine flu, and how assisted living nurses can prepare for and manage the care for their residents, staff and themselves.

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Risk of Infection among Older Adults 

Changes in the body's immune function occur as a result of comorbidities but also because of a normal age-related change known as “immune senescence.”² The clinical outcome of this phenomenon (attributed to T-cell changes) is reduced response to an infectious agent.² Given the normal age-related changes of diminished gag or cough reflex, older adults are at risk for respiratory infections. An individual with chronic obstructive pulmonary disease is at greater risk of contracting a lower respiratory tract infection than an older adult whose alveolar areas of the lungs are not disease-compromised. Pneumonia in an older adult with cardiac or neuromuscular comorbidity (e.g., cerebrovascular accident, Parkinson's disease) is associated with increased mortality. Undernourished older adults (i.e., serum albumin 3.0–3.5g/dL) appear to have a compromised immune function. However, the evidence for enhanced nutritional intake on improved immune system performance is not established.

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Presentation of Infection 

In 30% to 50% of older adults, fever—the most common feature of infection—can be absent.² This is a normal age-related change and is attributed to alteration in the body's ability to regulate temperature. Fever in an older adult is 2 or more degrees Fahrenheit (°F) over the individual's known baseline or an oral temperature greater than 99 °F or a rectal temperature greater than 99.5 °F.² Other common representations of infection—typical in older adults but not in younger adults—can be confusion, falls, change in ambulation or self-care ability, diminished food and/or fluid intake, and exacerbation of comorbidities, such as, atrial fibrillation.²

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Definitions Related to Infection Control 

These definitions are taken from the CMS Interpretive Guidelines for Long-Term Care Facilities.³

•Community-associated infection: also known as “community-acquired infection,” that is, an infection that was present or incubating at the time (or within 72hours) of admission.

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Pneumonia 

More than 50% of all cases of pneumonia are among older adults who experience, not coincidentally, more than 3 to 5 times the mortality than younger adults with pneumonia.² Commonly caused by the inhalation of oropharyngeal or gastric contents (even among those with a nasogastric or gastrostomy feeding tube) into the lower airway, the following signs and symptoms of aspiration pneumonia can be observed or complained of: fever and chills, cough, muscle pain and weakness or lethargy, shortness of breath at rest and on exertion, pleuritic chest pain defined as “sharp pain usually on one side of the chest” (p. 284), loss of appetite, headache, and nausea and vomiting. Antibiotics are the treatment of choice. Prevention includes management of all chronic diseases as well as pneumococcal vaccination every 7 to 10 years.⁴

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Influenza 

Of the almost 40,000 deaths annually caused by viral influenza in the United States, almost all occur among older adults.² Symptoms generally appear in 1 to 4 days after exposure to the virus by airborne droplet or direct contact with the saliva or mucous of an infected individual. Similar to the symptoms of a common cold but developing more rapidly and severely, the older adult may complain of a dry cough, sore throat, runny nose, sweating, nausea, malaise, and “burning” eyes.² Fever can rise rapidly and reach 104 °F, leaving the older adult feeling exhausted and depleted. (“Stomach flu” is caused by a different virus.) Treatment is effective if instituted with 24 to 48hours of onset. Although M2 inhibitors such as amantadine and rimantadine are effective, they are not recommended for older adults because of their side effects.² Neuraminidase inhibitors such as zanamivir (Relenza) and oseltamivir (Tamiflu) are safer and recommended for older adults.⁵ Influenza vaccination, annually in early fall, is 60% to 80% effective in preventing severe illness requiring hospitalization and even death.

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Tuberculosis 

Approximately 16 million people are infected with Mycobacterium tuberculosis (MTB) in the United States, one fourth of whom are older adults.² (Data indicate that 1.7 billion people are infected, worldwide).² Currently active cases are due to reactivation of the infection and do not present with the classical signs and symptoms of MTB: cough, night sweats, positive sputum, weight loss, and fever. Rather, older adults with active disease may have a low-grade fever, complain of fatigue and loss of appetite, and be less able to perform their normal functions. Interpretation of the purified protein derivative (PPD) skin test can be tricky. Induration—a hard, red, raised area—measuring 15mm or larger after 48 to 72hours is considered positive (i.e., active MTB). In ALCs, however, induration at or greater than 10mm is considered positive.² Hence, a 2-step test-retest PPD procedure in a 2-week period is recommended for ALC residents. A positive result is a 10mm or greater induration in the second test or an increase of the induration of 6mm or more from the first test. Treatment involves 4 medications: isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin (p. 285).² There can be significant side effects and drug-drug interactions with these medications. The treatment often has to be modified for older adults.

MRSA 

Older adults and individuals with compromised immune system function are most at risk for MRSA, a strain of Staphylococcus resistant to the broad-spectrum antibiotics that are used to treat it.² Staph-infected skin lesions, acquired in acute care or in the community (ALC or external), generally start as small red bumps that look like a pimple or boil that can quickly evolve into a painful, deep abscess. Some can require surgical drainage. Although the staph bacteria can remain on the skin only, they can also penetrate into the bones, lungs, joints, heart valves, bloodstream, and surgical wounds, causing a life-threatening infection.² Treatment is with antibiotics. An MRSA carrier can be freed of the microorganism by daily washing with chlorhexidine (available over-the-counter as Hibistat, Betasept, Spectrum-4, etc.) and bacitracin ointment application into the nostrils using a cotton swab for 6 to 8 weeks at a minimum.²

At present, the CDC offers no specific guidelines for ALCs with respect to the use of contact precautions and resident isolation in cases of MRSA. They do recommend, however, use of Standard Precautions (described later) to prevent the spread of infection, in general, in residential care settings.

C. difficile 

Also known as “infectious diarrhea,” C. difficile infection is common among older adults, whose risk is increased after a course of antibiotic therapy. The infection can be spread by person-to-person hand contact. Presentation of frequent, watery, and foul-smelling feces; abdominal cramps; fever; an elevated white blood count; and abdominal tenderness and distention is characteristic of C. difficile infection.², ⁶ Treatment with metronidazole (Flagyl), 250mg, by mouth, every 6hours for 10 days is usually effective.⁶ If symptoms are not relieved and the resident remains uncomfortable and continues to experience diarrhea, 125mg of oral vancomycin (Vancocin) should be administered every 6hours.⁶

It is important that staff and families (visitors) know that alcohol-based cleansers will not kill C. difficile. Soap-and-water handwashing is effective and should be rigorously implemented. Administration of “probiotics,” bacteria and yeast organisms that can restore balance to the gastrointestinal tract, is recommended for those at risk for or who already have C. difficile infection.² Probiotics are in yogurt and are also available in pill form.

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Common Infection Control Practices 

For persons with dementia living in ALCs, common infection control practices, such as handwashing, refraining from putting things into their mouths or touching their nose or mouth, or staying in a particular area, may be challenging. A catastrophic reaction could be precipitated if the resident is asked (or required) to wear a face mask or remain in a specific area. Each resident should have an individualized infection control plan, and this information should be readily accessible, especially to nonregular or float staff.

Education 

The ALC should have informed policies and decisions regarding how it will prevent infection and its spread. This includes education about contact with another resident or staff member with a communicable disease or infected skin lesion, food handling, and linen management. It also includes documentation and reporting mechanisms. Essential topics in education include but are not limited to Standard Precautions, infectious agent transmission (route), hand hygiene, MRSA and C. difficile, Transmission-based Precautions, and environmental sanitation (e.g., laundry, waste).³

Standard Precautions 

Formerly known as “Universal Precautions,” Standard Precautions are based on the premise that all blood, secretions (except sweat), excretions, broken skin, and mucous membranes may contain transmissible infectious agents. As such, prevention practices are applicable to any resident, not only residents with a suspected, presumed, or confirmed infection. Standard Precautions combine Universal Precautions and Body Substance Isolation.

Education about and implementation of Standard Precautions is the key to preventing transmission of infectious agents among residents and staff. Strategies include hand hygiene, appropriate use of personal protective equipment (PPE; e.g., gloves, gown, mask, eye shield, face shield), laundry and environment management, proper injection technique, waste control, and resident placement. Alcohol-based hand rubs (ABHR) cannot be used as a substitute for proper handwashing in food management, although they are acceptable for hand cleansing and direct resident care.³ It is important that personal care staff understand and appreciate the fact that gloves or baby wipes cannot substitute for hand hygiene. Implementation of standard precautions will vary with the nature of resident-staff interaction and the likelihood of body fluid, blood, and pathogen exposure.²

Transmission-based Precautions 

Also known as “Isolation Precautions,” these measures are implemented in addition to Standard Precautions to reduce or prevent transmission of infectious agents (pathogens). Transmission precautions are based on the means of transmission, that is, airborne, contact, and droplet. These precautions might have to be instituted when clinical signs and symptoms are present while awaiting lab and/or culture results (2 or more days). The appropriate PPE for the presumed type of infection and its transmission should be provided immediately, as should receptacles for their proper disposal. Transmission-based Precautions should remain in effect only as long as necessary to prevent transmission of the infection (i.e., the agent). The least restrictive approach should be used. The resident's plan of care (i.e., service agreement) should specifically list and describe the precautions in effect for the particular resident. Any roommates of the resident should also have detailed plans of care, as applicable. Documentation should describe the resident's emotional as well as physical status when transmission precautions are in effect. This could apply to the roommate, as well.

Airborne precautions prevent transmission of microorganisms that are infectious when suspended in the air (e.g., herpes zoster/varicella zoster also known as “shingles”; MTB).³ Staff members should wear a mask (or respiratory mask, depending on the infectious agent) before entering the room and discard it into a closed container placed close to the door, just before exiting the room. Proper hand hygiene should be done next in an area external to the resident's room. (Be sure to use the paper towel used to dry the hands to turn off the faucet.)

Contact precautions seeks to prevent person-to-person contact by using gown and gloves donned before entering the room. The PPE can be removed, and hands washed, in the resident's room.³ The resident's roommate can remain in the room if risk factors are limited or absent (e.g., no pressure ulcers or indwelling devices; patient is not immunocompromised).³

Droplet precautions (formerly known as “Respiratory Precautions”) seek to prevent transmission of infected respiratory droplets from an infected individual to a “host” mucosal surface, that is, another person at close proximity. Droplets are formed during coughing, sneezing, talking, suctioning, intubation, chest physiotherapy, and cardiopulmonary resuscitation. Respiratory viruses can enter through the nasal mucosa, conjunctiva, and mouth (less frequently) across a 3- to 10-foot distance.³ A mask should be used, and, depending on the microorganism, a roommate can remain in the infected resident's room if he or she has limited risk factors and the roommates' competence to exercise the precautions in which they have been instructed is assured.

The practice of “cohorting” confines infected or colonized residents (presence of microorganisms on or within the body; clinical signs and symptoms of infection) with the same infectious agent in one area. Staff are assigned to the cohort area only and do not care for residents in the noncohort area. In nursing homes, this can be done by cohorting a specific nursing unit or, if architecturally feasible because of corridors, a portion of the unit. The extent to which this could be accomplished in an ALC has not been reported or described; most likely, the resident would be asked to remain in his or her room.

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H1N1 Influenza 

Also known as “novel influenza” or “novel influenza A,” H1N1 influenza is a viral infection first detected in the United States in April 2009. (Note: H1N1 influenza can also be written as h1n1, that is, using lowercase letters.) Epidemiologists believe that it spreads from person to person likely in the same way that regular seasonal influenza spreads: by droplet transmission. However, new evidence suggests that the virus can be transmitted through the air (i.e., an airborne infection) but also through person-to-person contact and contact with surfaces exposed to the virus. Hence, it is important to instruct staff and visitors to wash their hands often and properly. The World Health Organization (WHO) has stated that the H1N1 virus is now the dominant influenza strain in most of the world.⁷

Most patients experience mild illness lasting only a few days.⁵ The virus can cause severe illness, especially in babies and toddlers, young and healthy individuals, pregnant women, and adults with chronic illness (e.g., respiratory disease, especially asthma, cardiovascular disease, diabetes, and immunosuppression) and in those who are obese.⁵ However, the number of deaths in proportion to the number of people infected is small and, unlike seasonal influenza, which typically affects older adults, has occurred primarily among young adults. Treatment should begin as soon as H1N1 influenza is suspected; ideally, within 48hours of becoming ill. The same drugs are used as for regular seasonal influenza.

Flu Pandemic 

A pandemic is declared when an infectious disease new to humans or the animal world is spreading over the globe. The most recent pandemic was AIDS, caused by the virus HIV, which was new to human beings. A flu pandemic is declared when transmission of a flu virus new to humans is occurring. Phases 3, 4, and 5 constitute the Pandemic Alert Period consisting of human infection with a new subtype, no or rare human-to-human spread and, if spread, then localized or limited.⁸ On June 12, 2009, the WHO officially recognized Phase 6, the highest level; it declared H1N1 influenza a pandemic.⁷ Human-to-human transmission was communitywide in 2 distinct areas of the globe: North America and Australia. WHO made clear that the issue was not one of severity of disease; in fact, the pandemic caused only moderate severity of illness. The word “pandemic” means “global”; it means nothing regarding severity but everything regarding spread.

Pandemic Safety Index (PSI) 

The PSI, recently developed by the CDC, is considered a “planning tool” for prevention. The index is based on the history of the last 3 influenza pandemics in the 20th century—the most recent being the Hong Kong flu pandemic in 1968 that killed an estimated 1 million people worldwide—and patterns of seasonal flu infection across communities, populations, and borders. The index is a “case fatality ratio” (CFR) that predicts the likelihood of dying with the disease (i.e., percent of deaths).⁹

“Social distancing” is based on the science of how the influenza virus spreads.¹⁰ The goal of social distancing is to reduce exposure, that is, public contact. It is applied to individuals, small and large groups, to an entire community or region, events (e.g., sports, theatre, movies) school, religious services, and mass transit. In 2009, social distancing was vigorously instituted in Mexico City, where the outbreak of H1N1 influenza was first noticed and reported. A PSI would be instituted after the WHO states that Phase 6 transmission is occurring in the United States. Categorized by setting—home, community, workplace—voluntary isolation and social distancing guidelines are recommended; voluntary quarantine is not ruled out.

H1N1 Vaccine 

The egg-based vaccine takes several months for drug companies to produce after receipt of the “seed stock virus” from the CDC. There is considerable testing for efficacy and safety. Distribution by early Fall 2009 (October) was delayed by slowed production of the vaccine, establishment of dosage parameters, and identifying those segments of the population that should have priority for vaccination. The 2-step vaccination was recommended for children under 9 years of age but not for infants younger than 6 months old.

The WHO recommends vaccinating health care workers first.⁷ The U.S. Department of Homeland Security and Department of Health and Human Services, charged with allocation and oversight of the H1N1 vaccination program, appears to agree at the time of this writing. Allocation consists of 5 tiers in the event of a declared influenza pandemic, starting with and in descending order¹¹:

Successive (tiers of) administration will be based on occupation, age, and health status. At present, it is unclear where older adults, in general, and those with chronic illness as described earlier, are located in the access tier. Assisted living nurses are advised to go to the ALC's respective state and federal government Web sites.¹²

For the most current information and recommendations (updated almost daily), go to http://www.cdc.gov/h1n1flu.

For state-specific information, go to: http://www.cdc.gov/h1n1flu/vaccination/statecontacts/htm. To contact the CDC directly by telephone, available 24/7, dial: (800) CDC-INFO–(800-232-4636);–TTY: (888) 232-6348.

Health Care Workers and ALC Staff Protection 

The Institute of Medicine has recommended that health care workers (but not the general public) should use a properly fitted N95 respirator mask when caring for a person with suspected or confirmed H1N1 influenza.¹³ “Caring” includes the provision of direct care as well as tray delivery and room cleaning. The protection offered by the respirator mask is significantly greater than that provided by the traditional surgical mask in that the former is able to block or filter out particulate matter. Some infection control specialists suggest that those suspected or confirmed with having H1N1 influenza should wear a surgical mask to impede outward transmission of the influenza virus.

Role of the Assisted Living Nurse in H1N1 Influenza Management 

Assisted living nurses and all staff working in ALCs should consider receiving H1N1 (h1n1) vaccination once it is available. As with other flu outbreaks, it is also critical that Standard Precautions (aka Universal Precautions) with good handwashing be implemented at all times. In the real-world setting of the ALC, it is impossible to isolate flu cases because it can be difficult to determine when a resident is infected, and it is also likely that he or she has already interacted with others and caused a spread of the disease. It may be helpful, however, in some ALCs, to prohibit visitors during periods of time in which there is a heavy local (i.e., external) community infection rate. Children coming into the facility, although a wonderful distraction for the resident, can carry this virus and spread it unknowingly. It may also be helpful to cohort residents so that those who are known to have H1N1 influenza can eat together in a separate area or at least visit with each other to prevent isolation when sick. Nurses and caregivers working in these sites need to protect themselves as well as their families through careful handwashing and wearing of masks and gloves. At present, there is no evidence of virus mutation or increasing strength or virulence of this pathogen.⁷ Stay abreast of developments; periodically check the various health agency Web sites, including those in your state.

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References 

1. Resnick B, Mitty E. Assisted living nursing. A manual for management and practice. New York: Springer Publishing Company; 2009;
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2. High KP, Resnick B. Infectious diseases. In:  Resnick B,  Mitty E editor. Assisted living nursing. A manual for management and practice. New York: Springer Publishing Company; 2009;p. 281–287
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3. CMS Manual System. Pub. 100–07. State Operations. Provider Certification. Transmittal 51. Interpretive guidelines for long-term care facilities (Tag F441, Infection Control). Available at www.cms.hhs.gov/transmittals/downloads/R51SOMA.pdf. Cited August 20, 2009.
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4. Bloom H, Resnick B. Prevention. In:  Resnick B,  Mitty E editor. Assisted living nursing. A manual for management and practice. New York: Springer Publishing Company; 2009;p. 105
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5. Centers for Disease Control and Prevention. 2009 H1N1 Flu (Swine Flu) and You. 2009 H1N1 Flu in Humans. www.cdc.gov/h1n1flu/qa.htm#b. May 6, 2009. Cited September 6, 2009.
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6. Triadafilopoulos G, Hauf J. Gastrointestinal diseases and disorders. In:  Resnick B,  Mitty E editor. Assisted living nursing. A manual for management and practice. New York: Springer Publishing Company; 2009;p. 315–320
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7. World Health Organization. Global Alert and Response. Preparing for the second wave: lessons from current outbreaks. www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html. Cited September 7, 2009.
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8. U.S. Department of Health and Human Services. WHO pandemic phases. www.hhs.gov/pandemicflu/plan/pdf/AppC.pdf. Cited September 7, 2009.
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9. Centers for Disease Control. Mitigation slides. www.cdc.gov/media/pdf/MitigationSlides.pdf. Cited September 7, 2009.
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10. Social Distancing to reduce the risk of pandemic influenza. www.socialdistancing.org. Cited September 7, 2009.
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11. U.S. Department of Health and Human Services. www.pandemicflu.gov/vaccine/allocationguidance.pdf. Cited September 7, 2009.
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12. Jacobson J. The pandemic (H1N1) virus vaccine. Am J Nurs. 2009;109:19
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13. Institute of Medicine. Report. Respiratory protection for healthcare workers in the workplace against novel H1N1 influenza A. Released September 3, 2009. www.nlm.nih.gov/medlineplus/news/fullstory_88947.html. Cited September 6, 2009.
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