Draft guideline for infection prevention and control in the long term care facility. Association for Practitioners in Infection Control.

Committee

The Guidelines Committee of APIC is in the process of developing a series entitled “APIC Guidelines for Infection Control Practice.” The first APIC Guideline, “Guideline for Use of Topical Antimicrobial Agents,” by Elaine Larson, RN, PhD, FAAN, was published in the December 1988 issue of the AMERICAN JOURNAL OF INFECTION CONTROL. The second Guideline, “APIC Guideline for Selection and Use of Disinfectants,” by William A. Rutala, PhD, MPH, was published in the April 1990 issue of the JOURNAL. The Guidelines Committee is now pleased to announce completion of the draft of the third APIC guideline for infection control practice: “Guideline for Infection Prevention and Control

in the Long Term Care Facility” by Philip W. Smith, MD, FACP, and Patricia G. Rusnak, RN. It is a working draft that is subject to general comment after having been reviewed by the Guidelines Committee, the APIC Board of Directors, and a number of national organizations. At this time we would like to invite all interested parties to comment on the proposed Guideline before its final approval and adoption by APIC. To be considered, comments must be received in writing no later than Monday, Jun. 7,1991. Please send your comments to: Marjorie A. Underwood, RN, BSN, CIC Chairman, APIC Guidelines Committee Manager, Infection Control Services Children’s Hospital of San Francisco 3700 California St. San Francisco, CA 94118

Draft guideline for infection prevention and control in the long term care facility Philip W. Smith, MD, FACP Patricia G. Rusnak, RN Omaha, Nebraska INTRODUCTION Hospital infection control is well established in the United States. Infection control committees began to appear in the 1960s in response to recognized institutional outbreaks of infectious diseases and increased regulatory pressures. Infection control programs are now manFrom the Bishop Infection Control

Clarkson Network.

Memorial

Hospital

and the Nebraska

dated in acute care facilities: virtually every hospital has an infection control practitioner (ICP) and many larger hospitals have a consulting hospital epidemiologist. The Study on the Efficacy of Nosocomial Infection Control (SENIC) documents the effectiveness of an infection control program that applies standard surveillance and control measures.’ The term nosocomial is often applied to the long term care facility (LTCF) as well as the

This draft APIC document is being made available only. It is not to be quoted, reproduced, circulated, to be considered either “final” or “published.”

for review and comment purposes or referenced. The document is not

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acute care hospital. The major elements leading to a nosocomial (institutionally associated) infection are the infectious agent, a susceptible host, and a means of transmission. These elements are present in LTCFs as well as in hospitals. It is not surprising, therefore, that almost as many nosocomial infections occur in LTCFs as in hospitals annually in the United States.* The 1980s has seen a recognition of the problem of infections in LTCFs, with subsequent widespread development of LTCF infection control programs, and definition -of the role of the ICP in LTCFs. Research studies delineate the descriptive epidemiology of nosocomial infections in LTCFs (see discussion of epidemiology below), and regulatory requirements are significantly increasing. Nevertheless, there are no SENIC-equivalent studies documenting the efficacy of infection control in LTCFs, and virtually no controlled studies have analyzed the effectiveness of specific measures in that setting. Application of currently available hospital infection control guidelines to the LTCF may be inappropriate and unrealistic in view of the different nature of infection control challenges that exist. Even .so, regulators occasionally do expect LTCFs to meet hospital standards. The problem is compounded by the varying levels of nursing intensity as well as the varying LTCF size and accessibility to physician input. An additional confounding variable is the increasing severity of illness in LTCF residents due in part to more rapid transfer of hospitalized patients because of the DRG-based hospital reimbursement system3 and the likelihood that LTCFs will share in the burden of caring for persons with AIDS. Any discussion of these issues must be made in the context of the LTCF as a community. The LTCF is a home for residents, a home in which they usually reside for months or years; comfort and infection control principles both need to be addressed. This Guideline is written for the LTCF infection control practitioner. It provides basic in-

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fection control recommendations that could be widely applied to LTCFs with the expectation of minimizing nosocomial infections. The efficacy of these measures in the LTCF, in most cases, has not been proven by prospective controlled studies, but is based on infection control logic and adaptation of hospital experience. Every effort will be made to address the unique concerns of LTCFs. EPIDEMIOLOGY Scope of guideline

This Guideline addresses all levels of care in the LTCF. The focus is specifically the LTCF, also known as the nursing home, caring for elderly or chronically ill residents. These recommendations should also generally apply to special extended care situations (e.g., institutions for the mentally retarded, psychiatric hospitals, rehabilitation hospitals). Background

By the year 2000, the US population age 65 85 is projected to increase by 15%, and the population age 85 and older will almost double from 2.6 million to about 5 million. Currently, approximately 20% of the latter group reside in LTCFs .4 It is well known that the elderly have a significantly increased incidence and severity of many infectious diseases.5-8 This vulnerability to infection is partly due to an age-related decline in immunologic function, specifically cellmediated immunity and antibody response.9 Furthermore, a number of underlying diseases known to increase the risk of infection are commonly seen in the elderly, such as diabetes mellitus and malignancy. Elderly patients in the hospital and LTCF are particularly susceptible to infection.” Several recent reviews have discussed the chain of infection as it applies to the LTCF.“, ‘* In addition to the generic susceptibility to infection in the elderly, the LTCF resident is a more susceptible host based on severity of underlying diseases, medications that affect resistance to infection



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(e.g., steroids and antibiotics), impaired mental status (predisposing to decubitus ulcers and aspiration pneumonia), incontinence, indwelling urinary catheters and other factors. Garibaldi noted that LTCF residents had an average of 3.3 underlying conditions recorded in the medical record and 12% had indwelling urinary catheters.13 There are many reservoirs for infectious agents in LTCFs. Most infections are thought to be endogenous, resulting from the resident’s own flora from the perineum, skin or nasopharynx. Infected or colonized residents may serve as reservoirs for certain infectious agents Stuphybcoccus au(e.g., methicillin-resistant retls); visitors and staff are also important reservoirs (e.g., influenza). Transmission is most frequently by direct contact (e.g., hands), but airborne, vehicle and vectorborne spread may occur. As in the hospital, health care providers go from room to room and bed to bed and serve as important sources for transmission by the contact route. Vehicle transmission occurs via such items as food and water, while airborne spread occurs by dissemination of droplet nuclei or particles in the air. A unique problem facing LTCFs is an ambulatory resident who may be incontinent or coughing and serves as a potential means for spread of infectious agents. Transmission in the LTCF may be accentuated by lack of handwashing facilities, absence of private rooms or deficiencies in ventilation systems. Nosocomial the problem

infections=magnitude

of

Nosocomial infections are those that develop after admission to the LTCF. Infections that are incubating at the time of admission, or develop within 48-72 hours of admission, are usually community-acquired, or hospital-associated, if the resident was transferred from an acute care setting. Because of the long length of stay in the LTCF, the vast majority of infections will be nosocomial.‘4 Classification of an infection as nosocomial does not imply that the LTCF

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caused the infection, or that it was preventable, but simply that it occurred in the LTCF. The Centers for Disease Control (CDC) estimates that 1.5 million nosocomial infections occur in LTCF residents per year; this translates to an average of one infection per resident per year.* Approximately a dozen surveys (most of them prevalence studies) of LTCF nosocomial infections have been undertaken, using a variety of surveillance techniques and definitions. The studies found nosocomial infection prevalence rates ranging from 2.7% to 32.7%, and incidence rates ranging from 10.7% to 20.1%, or 3.9 to 6.7 infections per 1000 resident days.13-*’ In view of the extended length of stay, infection rates per resident discharge would have little meaning in the LTCF setting; infections are calculated per 100 residents/month or per resident day. The most common infections found in LTCF surveys are urinary tract infections (UTIs), respiratory infections (influenza, pneumonia), infected decubitus ulcers, gastroenteritis and conjunctivitis.‘3-25 Specific nosocomial term care facility

infections

in the long-

Urinary tract infection. In most surveys the leading nosocomial infection in LTCFs is urinary tract infection (UTI), generally related to an indwelling urinary catheter. External catheters appear to be a risk factor for UT1 in male patients.26 A large percentage of LTCF residents are incontinent of urine or feces which also contributes to the risk of UTI. Bacteriuria is associated with incontinence and dementia, but may not by itself adversely affect survival.*’ In one large survey from Maryland the prevalence of urethral catheter use in LTCFs was 7.5%.*’ Catheterization predisposes to clinical UTI,*’ and the urinary tract is a frequent source of bacteremic infection in the LTCF.30 The vast majority of indwelling urinary catheters in the LTCF are colonized with >50,000 colony forming units of bacteria per cubic centimeter of urine,31 and the bacteria found are generally more resistant to oral antibiotics than



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the corresponding bacteria found in elderly in the community. “2 32-33Although residents with newly placed catheters have quantitatively less bacteriuria, routine catheter changes may not alter the course of bacteriuria or culture results, and are not advocated.34 Catheter-related bacteriuria is ever-changing and not amenable to prophylactic antibiotics.35, 36 Detailed guidelines are published for prevention of catheter-associated UTIs in hospitalized patients,37 and the recommendations are generally applicable to catheterized residents in LTCFs. The CDC guideline37 briefly discusses care of condom catheters and suprapubic catheters, but no guideline for leg bags is available. Leg bags allow for improved ambulation of residents, but probably increase the risk of UTI, since opening of the system and reflux of urine from the bag to the bladder occur more frequently than with a standard closed system. Respiratory tract infections. Pneumonia is a frequent infection in the LTCF. Streptococcus pnetrmoniae appears to be the most common etiologic agent.38 The evidence for the efficacy of pneumococcal vaccine in high risk populations, including the elderly, is debated.3g-42 However, the vaccine is safe and relatively inexpensive and is recommended for routine use in individuals over the age of 65 years.43 Aspiration pneumonia is also important in this setting. The mortality rate for LTCFacquired pneumonia is significantly higher than for community-acquired pneumonia in the elderly.44 Because of the impaired immunity of the elderly, viral upper respiratory infections that are generally mild in other populations may cause significant disease in the institutionalized elderly.“’ The CDC guideline for prevention of pneumonia46 is oriented towards acute care hospitals but covers respiratory therapy equipment and suctioning applicable to the LTCF. Influenza is a major threat to LTCF residents, who are among the high risk groups deserving preventive measures.47 Influenza outbreaks in LTCFs are common and severe. Clinical attack rates range from 25% to 60% and case fatality

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rates average 1O%.48-52Although concern has been expressed regarding the efficacy of the influenza vaccine in institutionalized elderly, most authors feel that the influenza vaccine is effective and indicated for residents and caregivers.53-56 Amantadine prophylaxis may be an effective adjunctive measure for influenza A, especially during an outbreak in an institution with a high percentage of unvaccinated elderly .57 Central nervous system side effects (such as insomnia, nervousness and confusion), more common in the elderly, require careful medical management and dosage adjustment of amantadine. Other measures recommended during an outbreak of influenza include restricting admissions and/or visitors during community outbreaks and cohorting of residents with influenza?’ A handbook with suggestions for managing an influenza vaccination program in the LTCF has been developed by the CDC.58 Tuberculosis (TB) has also caused extensive outbreaks in LTCFs, generally traced to a single ambulatory resident. Large numbers of staff and residents may be invo1ved.5g-62 Price found 8.1% of new employees and 6.4% of new residents to be PPD positive in her North Carolina survey, with significant 5-year skin test conversion rates in both groups.63 Guidelines discussing standards for control of tuberculosis in institutions are available.64-66 A guideline specific for long-term care is being developed by a joint task force of the American Thoracic Society and the Centers for Disease Control. There appears to be a consensus that TB skin testing of residents and personnel in the LTCF should be undertaken on a regular basis. The question of whether or not to use a 2-step TB skin test to survey for the booster effect is presently unresolved.66 Skin and soft tissue infections, infestations. Pressure ulcers occur in up to 24% of residents in LTCFs :8 Infected pressure ulcers require aggressive medical and surgical therapy; associated bacteremic infections have a high mortality rate.6g Medical factors predisposing to pressure ul-



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cers have been delineated,70 and several may be partially preventable (e.g., malnutrition and fecal incontinence). Prevention of pressure ulcers involves developing a plan for turning, positioning, elimination of pressure, reduction of shearing forces and keeping skin dry. Many physical and chemical products are available for the purpose of skin protection, debridement and packing although controlled studies are lacking in the area of pressure ulcer prevention and healing. A pressure sore flow sheet appears to be a useful tool in detecting and monitoring decubitus ulcers,7’ recording information such as ulcer location, depth, size, stage, and signs of inflammation, as well as ulcer care measures with recorded time. Since all pressure ulcers are colonized with bacteria, antibiotic therapy is not appropriate for a positive swab culture without signs and symptoms of infection. True infection of a pressure ulcer is a serious condition generally requiring parenteral antibiotics and surgical debridement. Scabies causes large outbreaks in long-term care institutions. 72 Diagnosis in an individual with a rash requires a high index of suspicion and skin scrapings. The presence of a proven case should prompt a thorough search for secondary cases. Treatment with lindane or crotamiton is usually effective,73 but repeat treatment, or treatment of all LTCF residents and personnel is occasionally necessary?* Therapy of rashes without confirming the diagnosis of scabies exposes residents unnecessarily to the toxic effects of the topical agents. Lice are occasionally seen, and treatment is described.74 Other infections. Viral gastroenteritis, salmonellosis and CZostridium perfrngens food poisoning cause diarrhea outbreaks in LTCFs. Recently E. coli 01.57 : H7, Clostridium dificile and Giardia lamblia have been added to the list of enteric pathogens in the LTCF.‘5-78 Bacteremia79 in the LTCF, although rarely documented, may be secondary to an infection at another site (pneumonia, UTI) or primary.

The CDC guideline for prevention of intravascular infections is a useful resource, and generally applicable to the LTCF.” Conjunctivitis in the adult presents as ocular pain, redness and discharge. In the LTCF, cases may be sporadic or outbreak-associated.13 Additional infections encountered in the long-term care setting include herpes zoster, herpes simplex infections, viral hepatitis, and cellulitis. The exact frequency and distribution of these infections varies from institution to institution. Epidemic long-term

nosocomial infections care facility

in the

Most LTCF nosocomial infections are sporadic, but epidemic clustering of infectious diseases can occur. An epidemic, or outbreak, implies the occurrence of cases in excess of the expected number. Outbreaks in LTCFs account for a significant proportion of reported epidemics.” Garibaldi13 noted this phenomenon in upper respiratory tract infections, diarrhea, conjunctivitis and multiply antibiotic-resistant bacteriuria. As discussed above, devastating outbreaks of tuberculosis and influenza are well documented, and scabies epidemics are a frequent problem. Salmonellosis has caused most of the large outbreaks of infectious gastroenteritis. In a study of 25 LTCF outbreaks, the average number of ill residents per outbreak was 22, with 48 deaths>* Significant outbreaks of infection have also been ascribed to E. coli7’, 76 and Streptococcus pyogenes.83 Finally, antibiotic resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) and multiply resistant gram-negative bacteria, are not simply a problem confined to hospitals, but cause outbreaks of colonization and infection in LTCFs .84-89 THE INFECTION CONTROL Current status of programs

PROGRAM

The increased attention devoted to infection control programs in the LTCF is evident. A sur-



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vey of Utah LTCFs13 noted that all homes had regular infection control meetings but none performed systematic surveillance for infections or conducted regular infection control inservices. All LTCFs had policies regarding the maintenance and care of catheters although the policies were not uniform. Price” surveyed 12 North Carolina LTCFs and found that although all 12 had a designated ICP, none had received special training in this area. Ten of the 12 conducted surveillance and all had an employee health program and a urinary catheter policy. Also noted were deficiencies in isolation facilities, particularly inadequate number of sinks and recirculated, inadequately filtered air. In a survey of Minnesota LTCFs, Crossley90 found that the majority had an infection control committee and a designated ICP although significant deficiencies in resident and employee health programs occurred. For instance, only 61% offered the influenza vaccine to residents and l/3 did not screen new employees for a history of infectious disease problems. A Maryland surveygl found that l/3 still performed routine environmental cultures, and many lacked proper isolation policies. Regulatory

aspects

The Health Care Financing Administration (HCFA) has published requirements for LTCFS.~* These apply to LTCFs that accept Medicare or Medicaid residents. HCFA has also published a long term care survey training manual that addresses many infection control questionsY3 Since the LTCF is an employer of health care workers, it must comply with federal and state Occupational Safety and Health Administration (OSHA) guidelines. Recent standards94 deal primarily with protection of workers from exposure to bloodborne pathogens such as human immunodeficiency virus (HIV) and hepatitis B (HBV). Other standards that apply to LTCFs include the federal minimum requirements for

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construction and equipment95 and the Joint Commission on Accreditation of Healthcare Organizations Long-Term Care Standards.96 In addition, many states have statutory requirements for LTCFs. The LTCF administrative staff should be knowledgeable about the federal, state and local regulations dealing with infection control in order to conduct a program in compliance with these regulations. The LTCF ICP should ideally be involved in the formation and revision of regulations, through local infection control and LTC organizations, to help assure the scientific validity of the regulations. Components of an infection control program

prevention

and

Overview. Several sources have discussed the components of an infection control program in the LTCF.97s 98 These components are generally drawn from regulatory requirements, current nursing home practices and extrapolations from hospital programs (see Table). An infection control committee and a designated infection control practitioner (ICP) are essential components of an effective infection control program. Most LTCFs have an infection control committee. However, the infection control committee is frequently less active in the LTCF than in the hospital, due in part to decreased physician availability. Unfortunately, the presence of an infection control committee may not be associated with the use of currently recommended infection control practices.99 A small working group consisting of the ICP, the administrator and the medical director may efficiently make most of the infection control decisions . Most authors feel that an infection control program should include some form of surveillance for infections, an epidemic control program, education of employees in infection control methods, policy and procedure formation and review, an employee health program, a resident health program, and monitoring of resident care practices. The ICP may also



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be involved in quality assurance, environmental review, antibiotic monitoring, product review/evaluation and reporting of diseases to public health authorities. The ICP is usually a staff nurse, a background that is helpful for resident assessment and chart review. The ICP i.s most commonly a registered nurse. Because of size and staffing limitations, the vast majority of LTCF ICPs have other duties such as director of nursing, floor nursing, inservice coordinator, employee health and quality assurance. The number of LTCF beds justifying a full time ICP is unknown, and will depend on the acuity of residents and the level of care provided. An LTCF with more than 250300 beds may need a full time ICP. The LTCF ICP, like the hospital ICP, requires specific training in infection control, well defined support from administration, and the ability to interact tactfully with personnel, physicians and residents. The LTCF infection control practitioner (ICP) will have a number of resources to draw upon, including the Association for Practitioners in Infection Control (APIC). APIC provides a certifying examination for both hospital and LTCF ICPs. The LTCF administrative staff needs to support the ICP with appropriate educational opportunities and resources, including expert consultation in infectious diseases and infection control as needed. Surveiliance. Infection surveillance in the LTCF refers to the collection of data on nosocomial infections. Traditionally outcome measures (e.g., number of urinary tract infections) are used rather than process measures (e.g., was correct catheter care procedure followed?). Surveillance data are used primarily to plan control activities and. educational programs, and to +-event epidemics, but surveillance may also detect infections that require therapeutic action. The feasibility of routine surveillance in LTCFs has been demonstrated, and data have been used to provide a basis for inservice edu-


Table 1. Components control

of LTCF infection

program Surveillance Outbreak Control Policies and Procedures Isolation/Precautions Resident Health Program Employee Health Program Education Antibiotic

Review

Product Review/Evaluation Disease Reporting Quality Assurance

cation.‘O(’ Surveillance needs to be simple and pragmatic, particularly because the ICP may be able to spend only a few hours per week on infection control activities.14 Surveillance requires objective, valid de&Gtions of infections. Most hospital surveillance definitions are based on the National Nosocomial Infections Surveillance (NNIS) system criteria,‘O’ but no such standard exists for long term care. NNIS definitions depend heavily on laboratory data and recorded clinical observations. In the LTCF x-ray and microbiology laboratory data are often unavailable, and written physician notes and nursing assessments in the medical record are usually extremely brief. Timely detection of nosocomial infections in the LTCF often depends upon recognition of clues to infection by nurses’ aides, and reporting of these findings to the licensed nursing staff. Although modified, LTCF-specific criteria have been suggested, ‘O”,lo2 there are currently no widely accepted, validated, clinical criteria for the diagnosis of nosocomial infections in the LTCF. A Canadian consensus conference in 1989 led to proposed criteria that are being studied

103, and Appendix

The surveillance process consists of collecting data on individual cases, and determining whether or not a nosocomial infection is present by comparing collected data to standard definitions (criteria) of infections. Walking rounds

This draft APIC document is being made available only. It is not. to be quoted, reproduced, circulated, to be considered either “final” or “published.”


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is one recommended data collection method in the LTCF,lo2 and provides the means to collect the concurrent, prospective infection data necessary to make infection control decisions. Surveillance should be done on a timely basis, probably at least weekly?* During rounds the ICP may use house reports from nursing staff, chart review, laboratory reports, kardex review and clinical observations as sources of information. Published LTCF surveys have been either incidence or prevalence studies. Prevalence studies detect the number of existing (old and new) cases in a population at a given time, while incidence studies find new cases during a defined time period. The latter is preferred, since more current information can be collected by an incidence study, if data is collected frequently enough. Recording, review, analysis and reporting of infection case data are usually done monthly, quarterly, and annually to detect trends. This process is facilitated by an individual infection report form, samples of which have been published.g8, lo4 Analysis of absolute numbers of infections is misleading; calculation of rates provides the most accurate information. Rates may be calculated using the average resident census (per month) as the denominator, or using resident days as the denominator. The average daily census is not an accurate denominator for hospitals, but can be used by LTCFs because the facility is usually full, and turnover is minimal. Rates should be calculated using the following formula:

$XK X = numerator (number of nosocomial infections) Y = denominator (average census/month OR resident days/month) K = constant use 10, 100, 1000 (whichever results in the smallestwhole number)

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EXAMPLE: K = 100 2 x 100 = 0.67/1000 300

K = 1000 2 x 1000 = 6.7/1000 300

Preferred K is 1000 because 6.7 is a whole number. Not all rates are expressed as a percent (% only used when K is 100). As an example, in a 30-day month, a LTCF with an average census of 200 has 1.5 new nosocomial infections: Infection (incidence) rate = # of new nosocomial infections occurring in the month x 100 Average monthly LTCF census =- 15 200 X 100 = 7.5 infections/100 resident months Since the K is 100, this can also be expresseed as 7.5% OR Infection rate = # of new nosocomial infections occurring in the month = x 1000 number of resident days in the month 15 = 2.5 infections/ 1000 resident days = (30) (200)

Infection control data, including rates, then needs to be displayed, distributed to appropriate committees and personnel, and used in planning infection control efforts. The data should lead to specific educational and control programs. In order to compare rates within your facility or with other facilities, the method of calculation must be identical (including the denominator and the constant). Even when calculation methods are consistent, infection rates may vary between facilities because of differ-



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ences in resident risk factors and disease severity, and comparisons may not be valid. Outbreaks. An important reason to collect and analyze surveillance data is for the early detection and prevention of infectious disease outbreaks. When the number of cases exceeds a normal baseline, an outbreak should be considered. The approach to investigation of an outbreak involves a number of steps, including determining if an outbreak has occurred, developing a case definition, analyzing the outbreak, formulating a hypothesis, designing control measures, evaluating control measures and making a report. Concurrently, the potential for spread of disease is evaluated and addressed.‘05 The LTCF may have difficulty responding to an epidemic with appropriate therapeutic measures (e.g., mass vaccination or administration of amantadine in an influenza outbreak) if consent needs to be obtained on short notice from a resident’s relatives or the primary physician. Developing a policy for obtaining prospective consent that gives the medical director or administration the power to act in an infectious disease emergency is one way to circumvent this problem. Ultimately, outbreak prevention depends upon key prevention strategies (e.g., influenza and pneumococcal vaccines). Isolation/precautions. An isolation/precautions system is an important means of preventing cross infection. The use of barrier precautions in LTCFs has been handicapped by lack of adequate bandwashing facilities, private rooms and appropriate ventilation systems.” The two traditional systems for implementing barrier precautions in the hospital were developed by the CDC. The category-specific system lists seven categories of isolation/precautions based on means of disease transmission: strict isolation, contact isolation, respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretion precautions and blood/body fluid precautions. The diseasespecific system lists all relevant contagious dis-

41 A

eases and the recommended barrier methods (e.g., gowns, gloves and a private room for an incontinent patient with salmonellosis). Discussions of the relative merits of the two systems are available’06, ‘O’; in general, the category-specific system is simpler to use, but the disease-specific system consumes fewer resources since precautions are tailored to the specific disease. The acquired immunodeficiency syndrome (AIDS) profoundly affected institutional isolation issues. Proposed Occupational Safety and Health Administration (OSHA) regulations mandate the concept of Universal Precautions, designed to protect the health care worker from bloodborne pathogens, including HIV and HBV.g4. lo8*log In this system, all blood and body fluids are potentially infectious. Education, provision of needle-disposal units, provision of protective equipment (e.g., gloves, gowns and protective eyewear) and monitoring compliance are part of Universal Precautions. A third isolation system, body substance isoZation, is an attempt to combine Universal Precautions and a standard isolation system.‘l” The elements of this system include clean gloves for contact with nonintact skin or mucous membranes of all patients, handwashing for soiling or before new patient contacts, additional barriers as needed to protect from body substances, and private rooms for patients with communicable diseases transmitted via the air. A fourth option, possibly most appropriate for the LTCF, is to design a custom isolation system appropriate for the needs of the specific institution. Elements of the three systems above may be incorporated, but any custom system must address Universal Precautions and federal/state regulations. Several conditions require use of a private room (e.g., tuberculosis and major wound infections caused by Staphylococcus aweus), but the LTCF may need to transfer infected residents to an acute care hospital if adequate isolation facilities are not available. In one



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study, a negative pressure room was improvised by placing a fan blowing outward in the LTCF isolation/precautions room.14 Isolation/precautions policies need to define authority. The nurse should have the authority to initiate precautions without a physician’s order in an emergency, and a policy for this should be developed. Handwashing appears to be the most important infection control measure in the LTCF as well as the hospital. Several published guidelines for handwashing and choice of antiseptic agent are applicable.“‘* ‘12 In general, handwashing with bar or liquid soap is adequate in the LTCF. Infections are an important reason for transfer of LTCF residents to acute care hospitals.l13 LTCF-hospital transfers result in a dynamic microbiologic equilibrium, making interinstitutional epidemics a concern.*‘, ES Minimizing spread of hazardous organisms requires open and honest communication between hospital and LTCF ICPs. Resident health. Resident health programs are felt to be important in prevention of nosocomial infections, lo2 but comprehensive resident health programs are often lacking in LTCFs.” One of the major functions of a resident health program is the immunization of the elderly resident.43, 47 It is recommended that residents receive TB skin testing on admission,66 and chest x-rays if PPD positive or symptomatic. Resident care practices to be addressed by a resident health program include prevention of aspiration, skin care, prevention of UTIs and oral alimentation. Employee health. A guideline for infection control in hospital personnel has been published by the CDC.‘14 Most of this CDC guideline is applicable to LTCF personnel. No guidelines specifically for LTCF personnel have been developed, although an employee health program including an initial health assessment to ensure the absence of communicable disease is re-

quired,92 and OSHA proposed regulations concerning protection of employees from bloodborne pathogens apply to the LTCF.g4p lo8plog Initial assessment of employees and education in infection control are also important, as is a reasonable sick-leave policy?’ Tuberculosis is a primary concern in initial employee screening.63, 66 Employee health policies and procedures should also address post-exposure followup and/or prophylaxis for certain infections such as HIV, hepatitis B, tuberculosis, and scabies. Education. The value of education in the LTCF has long been recognized, and attitude surveys of personnel confirm the need for education.“’ The importance of education is accentuated by the great turnover in LTCF personnel. Surveillance information is an excellent starting point for an infection control inservice, and walking rounds provides an opportunity for the ICP to provide timely, informal education to personnel . Infection control content should include information on disease transmission, handwashing, barrier precautions, and basic hygiene. In addition, all individuals with direct resident care responsibility need education in early problem/symptom recognition. The teaching methods used need to be sensitive to language, cultural background and educational level. A coordinated effective educational program will result in improved infection control activities.‘16 Antibiotic usage and resistance. Antibioticresistant bacteria pose a significant hazard in the LTCF, and this resistance develops largely as a consequence of antibiotic usage. Antibiotics are used in about 7% to 10% of residents in LTCFs, frequently for lengthy periods of time.“’ Several studies have questioned the appropriateness of many such courses of antibiotics.118~ ‘19 A common problem is the confusion of infection with colonization (e.g., positive swab culture of a decubitus ulcer or bacteriuria without signs or symptoms of infection), and treatment of the latter with antibiotics.



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Control of antibiotic-resistant bacteria may be undertaken at one of two points.120 The ICP may become involved with the medical director, administrator or pharmacist in an antibiotic education or control program to decrease antibiotic usage. Alternatively, barrier (isolation) precautions are necessary to prevent cross-infection with known resistant microorganisms (e.g., methicillin-resistant Stuphylococcus aureus). AIDS. The increasing burden of care for persons with AIDS is being shared by the LTCF, especially for individuals who are too sick to reside at home but do not require acute hospital care. Guidelines for dealing with HIV infection in the health care setting are incorporated widely in hospitals, but also apply in the LTCF. ‘08,lo’. 12’ A manual specifically addressing AIDS in the nursing home has been published.122 Issues to be considered include development of policies for acceptance of residents with HIV infection, protection of employees (e.g., needle disposal units), education of employees, HIV positive employees, confidentiality issues, cost of care and social concerns. Residents infected with HIV do not require any isolation or precautions beyond those previously discussed unless they have certain contagious secondary infections such as pulmonary tuberculosis (see Isolation/Precautions above). The institution should develop plans for HIVrelated issues. At least one survey has suggested the need for education in the LTCF regarding AIDS-related attitudes,123 and such education is required in the proposed OSHA regulations?4 Other aspects of the program. An important aspect of the infection control program is the development and updating of infection control policies and procedures. Resources are available on writing policies and procedures in genera1,124* 125laundry policies, 93,98zlo4,126 dietetic service policies,93, 98*lo4 physical therapy policies,%, 127and handwashing .‘llr 112No policy or


procedure is more important than those addressing handwashing. The policy details specific indications for handwashing (including when coming on duty; whenever hands are soiled; after personal use of toilet; after blowing or wiping nose; after contact with resident blood or body secretions; before performing any invasive procedures on a resident; after leaving an isolation room; after handling items such as dressings, bedpans, catheters, urinals; after removing gloves; before eating; and upon completion of duty), while the procedure lists explicit steps in the handwashing process. Selection of proper disinfectants and antiseptics is difficult, and requires the input of the ICP. The participation of the ICP is also essential in evaluating sterilization and disinfection issues, such as monitoring reuse of disposable equipment. Resources are available.124, I28 The ICP may be asked to advise on additional products that affect infection prevention such as urinary catheter systems, gloves and disposable diapers. Quality, efficacy and cost issues need to be weighed in product selection.124 Medical waste issues are the focus of much controversy, and there is a disparity between Environmental Protection Agency (EPA) regulations and CDC recommendations.129 The ICP may be involved in medical waste issues relevant to the LTCF, and several resources are available.93,

112, 129, 130

Another important function of the infection control program is disease reporting to public health authorities. State health departments provide a list of reportable diseases. Finally, the increased emphasis on quality assurance (QA) in health care is likely to become evident in long term care. Infection control is an important form of QA, and the ICP’s skills are well suited to addressing QA measurement issues.13’ The ICP, in the course of performing control activities such as surveillance, is able to monitor compliance with policies and procedures, and to provide informal infection control education to correct observed problems.



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RECOMMENDATIONS

A. Infection Control Program 1. An active, effective, facility-wide infection control program should be established in the long term care facility (LTCF). 2. The elements of the program should include: a. A surveillance system based on written criteria for nosocomial infections in residents b. A system for detection, investigation and control of institutional outbreaks of infectious diseases c. An isolation/precautions system to reduce risk of transmission of infectious agents d. Infection control policies and procedures e. Inservice education in infection prevention and control f. A resident health program g. An employee health program h. A system for antibiotic review and control i. Product review/evaluation j. Disease reporting to public health authorities 3. The infection control program should be in compliance with federal, state and local regulations. B. Infection Control Committee (ICC) 1. An ICC should oversee the infection control program for the facility. Members should include the infection control practitioner, the medical director, and representatives from nursing, administration, and pharmacy. Participation of other departments such as dietary, housekeeping, and physical therapy should be considered on an ad hoc basis. 2. The ICC should meet on a regular basis, at least quarterly, and as needed. 3. The ICC should keep written minutes of

Journal of CONTROL

all meetings, and the minutes should reflect problem identification and followup action. 4. The ICC should establish policies and procedures for investigating, controlling and preventing infection transmission in the facility. 5. The infection control policies and procedures should be approved, reviewed and revised by the infection control committee. 6. Employees should be made aware of infection control policies and procedures. 7. The ICC should develop a system for monitoring staff compliance with infection control policies and procedures . 8. The ICC should develop a system for reporting notifiable diseases to proper public health officials. C. Infection Control Practitioner (ICP) 1. One person, the ICP, should be assigned the responsibility of directing infection control activities in the LTCF. The ICP should be someone familiar with LTCF resident care problems. 2. The ICP is responsible for implementing, monitoring and evaluating the infection control program for the LTCF. 3. The ICP should be guaranteed sufficient time to carry out the directives of the ICC. 4. The ICP should have a sufficient infection control knowledge base in order to carry out responsibilities appropriately. A basic background in infectious diseases, microbiology, geriatrics and educational methods is advisable. Management and teaching skills are also helpful. Continuing education is essential for the ICP. 5. The ICP should have written authority to institute infection control measures (e.g., isolation or visitor restrictions) in emergency situations. 6. The ICP should be knowledgeable of the



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federal, state and local regulations dealing with infection control in the LTCF. 7. The ICP should communicate with other relevant facility committees. 8. The ICP should communicate openly with other health care facility ICPs about residents transferred into the LTCF, or from the LTCF to an acute care hospital, for the purposes of assuring appropriate isolation and collecting surveillance information. D. Surveillance 1. The LTCF should have a system for ongoing collection of data on nosocomial infections in the institution. 2. The ICC should monitor surveillance data and recommend infection control measures as appropriate in response to identified problems. 3. Concurrent, prospective surveillance is preferable to retrospective surveillance. 4. The frequency of surveillance for nosocomial infections should be based on factors such as acuity of resident population. Surveillance at least once a week is generally needed to collect timely data. 5. A documented surveillance procedure should be used, including written definitions of infections. 6. Surveillance data should be collected primarily from walking rounds in the LTCF. Medical progress notes in the chart, laboratory reports, nursing notes, kardexes, medication records, physical assessment, environmental observations and followup information from transfers to acute care hospitals provide clues to the presence of infections. 7. Surveillance data should be used for planning control efforts, detecting epidemics, ‘directing inservice education and identifying individual resident problems for intervention. 8. Analysis of surveillance data should include at l.east the following elements on

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each infection to detect clusters and trends: date of onset, body site, geographic location and appropriate culture information. An infection surveillance report form facilitates recording of data on residents with nosocomial infections. 9 Infection rates should be calculated periodically (e.g., monthly, quarterly, and annually), recorded, analyzed, and reported to the administration and the ICC. Nosocomial infection rates are calculated as nosocomial infections per 100 residents per month, or infections per 1000 resident days. A standard infection report form facilitates reporting of surveillance information. Tables, graphs, and charts may be used. 10 In addition to collection of baseline infection rates, the ICP should perform special studies focused on perceived problems. Examples of special studies are a study of UTIs in catheterized residents or a study of the occurrence of influenza in vaccinated vs. unvaccinated residents. 11 Measures should be instituted to correct unsafe and unsanitary practices. Environmental cleanliness may be monitored by walking rounds using a check list for each area of the LTCF. Nursing interventions may be monitored by direct observation during surveillance rounds. E. Outbreak Control 1.. Surveillance data should be used to detect and prevent outbreaks in the LTCF. 2. The facility should define authority for intervention during an outbreak, including the authority to relocate residents, confine residents to their rooms, restrict visitors, obtain cultures, isolate and administer relevant treatment (e.g., amantadine during an influenza outbreak). 3. The LTCF should have an administrative



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protocol for dealing with infectious disease, epidemics. 4. The occurrence of even a single verified case of tuberculosis, influenza, scabies, or infectious gastroenteritis (e.g., salmonellosis) in the LTCF should prompt consideration of an outbreak, notification of appropriate individuals (e.g., medical director, administrator, and local health department), and a search for secondary cases. A nosocomial case of TB in the facility should prompt repeat PPD skin testing and evaluation of residents and employees. 5. In order to facilitate response to an outbreak, consent for appropriate diagnostic or therapeutic measures should be obtained from the resident, the resident’s family, or the resident’s primary physician prospectively, ideally on admission to the facility. 6. Culturing of inanimate environment or personnel is not recommended unless warranted in the course of an epidemic investigation. F. The Facility 1. Handwashing facilities that are conveniently located and adequate supplies should be available for residents and staff. 2. Clean and dirty utility areas should be separate and designated. 3. Appropriate ventilation and air filtration should be addressed by the LTCF. Each LTCF should be able to provide a room with negative air pressure or ventilation of air to the outside if strict or respiratory isolation is instituted. 4. Housekeeping in the facility should be performed on a routine and consistent basis to provide for a safe and sanitary environment. Cleaning schedules for all areas in the LTCF should be kept. Cleaning products should be approved by the ICP, and manufacturers’ recommenda-

Journal of CONTROL

tions for use and dilution should be followed. 5. Laundry policies and procedures should address: proper bagging of linen at the site of use, transporting linen in appropriate carts, cleaning of the carts on a regular basis, separation of clean and dirty linen, covering of clean linen, and protection of personnel handling dirty laundry. Adequate supplies of clean linen should be available. Hands should be washed after handling soiled laundry. 6. Dietetic service area policies a-?d procedures should address the following: Cleaning of food preparation areas, food storage, and employee health. 7. Policies and procedures covering infection control aspects of physical therapy (including cleaning of hydrotherapy tanks) should be developed. 8. Policies and procedures for disposal of infectious medical waste (including waste collection, transport, and disposal) should be developed in accordance with state and local regulations. 9. If pets are allowed, the LTCF should have a policy defming access, containment, cleanliness, and vaccination of pets. C. Isolation/Precautions 1. Isolation/precautions policies and procedures should be developed, evaluated, updated, and monitored for effectiveness . 2. Private rooms used for isolation/precautions should have readily accessible toilet and handwashing facilities, and should be identified by precautionary signs. 3. Each LTCF providing a private room for isolation/precautions should address handwashing facilities and ventilation (see Section F). 4. Regardless of isolation/precaution system used, Universal Precautions should be fully implemented.



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5. Used needles and syringes should not be manually recapped, broken or bent, and disposed of along with sharps in an impervious container. 6. After instituting isolation/precautions, assessment of other exposed residents should be made in a timely fashion to detect other cases. 7. The facility should have infection control policies dealing with acceptance and transfer of residents with infectious diseases. H. Asepsis/ Handwashing 1. Handwashing should be encouraged and monitored in the LTCF. 2. A handwashing policy and procedure should be developed by the LTCF. 3. Policies and procedures for disinfection and sterilization should be developed to address such issues as sterile supplies, use of disposable items, and disinfection of equipment (e.g., thermometers). 4. All items, other than disposables, shall be cleaned, disinfected, or sterilized following published guidelines and manufacturers’ recommendations. 5. The infection control committee should identify those resident care procedures that require aseptic technique. I. Resident Care 1. Resident rooms should have an accessible sink with soap, water, towels, and toilet facilities. 2. Provision should be made for maintaining adequate resident personal hygiene, and instructing residents in hygiene and handwas:hing as appropriate to their functional status. 3. Resident skin care should include: routine frequent turning for those unable to do so themselves, keeping the resident clean and dry, inspection of all residents’ skin on a routine basis, ensuring appropriate nutrition, and the treatment of pressure ulcers. Turning schedules and


pressure ulcer assessment forms may be useful. 4. In general, the CDC guideline for prevention of urinary tract infections is applicable and should be followed. Adequate hydration should be maintained in residents. If leg bags are used, the LTCF should develop policies and procedures for aseptic connection, cleaning, and storage of leg bags. 5. A program to minimize the risk of pneumonia in the LTCF should address immunizations (see resident health program), reducing the potential for aspiration, minimizing atelectasis and care of respiratory therapy equipment. 6. Policies and procedures should be developed for prevention of infections associated with nasogastric and gastrostomy tubes, including preparation, storage, and administration of solutions. 7. Policies and procedures should be developed for prevention of intravascular infections, if intravascular devices are used. 8. The LTCF should develop policies and procedures for dealing with HIV-positive residents. J. Resident Health Program 1. Each resident should have an initial history (including significant past and present infectious diseases), immunization status evaluation and recent physical exam, and intradermal (Mantoux) tuberculin (PPD) skin test. A recent chest x-ray is advisable if the PPD is positive. 2. All newly admitted residents should receive tuberculosis (TB) screening by the intradermal purified protein derivative (PPD) method unless a physician’s statement is obtained that the resident had a past positive reaction to PPD. When new or active TB is suggested by a positive PPD result or by symptoms, a chest x-ray and medical evaluation should be



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obtained. A two-step booster technique may be used for those over the age of 45. 3. Followup skin testing for TB should be performed every 1 to 4 years (depending on the regional prevalence of TB and/or local regulations) or following discovery of a new case of TB in a resident or staff member. The intradermal PPD method should be used. 4. Each resident should receive tetanus/diphtheria vaccine every 10 years. This should be recorded in the resident’s chart. 5. Each resident should receive the pneumococcal vaccine one time. This should be recorded in the resident’s chart. 6. Each resident should receive the influenza vaccine annually in the fall, unless medically contraindicated. This should be recorded in the resident’s chart. 7. Policies and procedures addressing visitors should be developed, to deal with introduction of community infections (such as influenza) into the LTCF. K. Employee Health 1. All new employees should have a baseline health assessment including immunization status and history of significant past or present infectious diseases. Screening cultures of new employees (such as stool cultures) are rarely indicated. 2. All new employees should receive TB screening by the intradermal (Mantoux) PPD method unless a physician’s statement is obtained stating that the employee had a positive reaction to .PPD. When new or active TB is suggested by a positive PPD result or by symptoms, a chest x-ray and medical evaluation should be obtained. A twostep booster technique may be used for employees over the age of 45. 3. Followup skin testing for TB should be

INFECTION

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performed every 1 to 4 years (depending on the regional prevalence of TB and/or local regulations), or following discovery of a new case of TB in a resident or staff member. 4. All employees should have current immunizations with documentation in the employee record, including tetanus/diphtheria vaccination every 10 years. 5. Employees with frequent blood/body fluid contact should be offered hepatitis B vaccine. 6. Employees should receive the influenza vaccine annually in the fall. 7. Each employee should be taught basic hygiene and handwashing, and to consider blood and all body fluids as potentially infectious. 8. All employees should be educated to report any significant infectious illnesses to the staff member responsible for employee health. 9. Each employee record should include immune status (natural or acquired), illnesses and incidents such as significant exposures to contagious diseases, needlesticks, injuries, and accidents. 10. The LTCF should develop written protocols for managing employee illnesses and exposures (e.g., to hepatitis B, HIV, TB, scabies). 11. An employee absentee policy that does not encourage the employee to work while ill should be developed. 12. The LTCF should develop policies and procedures for dealing with the HIVpositive employee. L. Education 1. Infection control inservice education should be provided at the initiation of employment and ‘regularly thereafter. Training should include all staff, especially those providing direct resident care.



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2. All programs should be documented with the date, topic, names of attendees, and evaluations. 3. Program topics should be timely and relevant to infection prevention. Basic hygiene, handwashing, transmission of infectious diseases, employee health, Universal. Precautions, and the susceptibility of residents to infectious diseases are topics to be included. The ICP may recommend inservice topics. Surveillance data is of interest to staff, and may be included in inservices as appropriate. M. Antibiotic Resistance and Review 1. The ICP should monitor antibiotic sensitivity results from cultures to detect clinically significant antibiotic-resistant bacteria in the institution. Changes in antibiotic sensitivities should be communicated to the ICC. 2. The ICC should periodically assess antibiotic utilization trends in the LTCF. References 1. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205. 2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol1985;121:15967. 3. Sager MA, Easterling DV, Kindig DA, Anderson OW. Changes in the location of death after passage of Medicare’s prospective payment system. N Engl J Med 1989;320:433-9. 4. US Senate Special Committee on Aging. Aging America-trends and projections. 1988 edition. 5. Schneider EL. Infectious diseases in the elderly. Ann Intern Med 1983;98:395-400. 6. Garibaldi RA, Nurse BA. Infections in the elderly. Am J Med 1986;81(suppl lA):53-8. 7. Yoshikava TT. Geriatric infectious diseases: an emerging problem. J Am Geriatr Sot 1983;31:34-8. 8. Gleckman RA, Gantz NM. Infections in the elderly. 1st ed. Boston: Little, Brown, 1983. 9. Smith PW. Nosocomial infections in the elderly. Inf Dis Clin N Am 1989;4:763-77.

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10. Felser JM, Raff MJ. Infectious diseases and aging: immunologic prospectives. J Am Geriatr Sot 1983;31: 802-6. 11. Jackson MM, Fierer J. Infections and infection risk in residents of long-term care facilities: a review of the literature, 1970-1984. AM J INFECT CONTROL 1985; 13:63-77. 12. Smith PW. Nursing home-acquired infections: What to do about control and treatment. Postgrad Med 1987;81(6):55-66. 13. Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes: policies, prevalence and problems. N Engl J Med 1981;305:731-5. 14. Scheckler WE, Peterson PJ. Infections and infection control among residents of eight rural Wisconsin nursing homes. Arch Intern Med 1986;146:1981-1. 15. Price LE, Sarubbi FA Jr, Rutala WA. Infection control programs in twelve North Carolina extended care facilities. Infect Control 1985;6:437-41. 16. Lester MR. Looking inside 101 nursing homes. Am J Nurs 1964;64(8):111-6. 17. Cohen ED, Hierholzer WJ, Schilling CR, Snydman DR. Nosocomial infections in skilled nursing facilities: a preliminary survey. Public Health Rep 1979;94: 162-5. 18. Magnussen MH, Robb SS. Nosocomial infections in a long-term care facility. AM J INFECT CONTROL 1980; 8:12-7. 19. Gambert SR, Duthie EH Jr, Priefer B, Rabinovitch RA. Bacterial infections in a hospital-based skilled nursing facility. J Chron Dis 1982;35:781-6. 20. Farber BF, Brenen C, Puntereri AJ, Brody JP. A prospective study of nosocomial infections in a chronic care facility. J Am Geriatr Sot 1984;32:499-502. 21. Nicolle LE, McIntyre M, Zacharias H, MacDonell JA. Twelve-month surveillance of infections in institutionalized elderly men. J Am Geriatr Sot 1984;32: 513-9. 22. Standfast SJ, Michelsen PB, Baltch AL, et al. A prevalence survey of infections in a combined acute and long-term care hospital. Infect Control 1984;5:177-94. 23. Setia U, Serventi I, Lorenz P. Nosocomial infections among patients in a long-term care facility: spectrum, prevalence and risk factors. AM J INFECT CONTROL 1985;13:57-62. 24. Franson TR, Duthie GH Jr, Cooper JE, Van Oudenhoven G, Hoffman RG. Prevalence survey of infections and their predisposing factors at a hospital-based nursing home care unit. J Am Geriatr Sot 1986;34:95100. 25. Alvarez S, Shell CG, Woolley TW, Berk SL, Smith JK. Nosocomial infections in long-term facilities. J Geronto1 1988;43(1):m9-m17. 26. Ouslander JG, Greengold B, Chen S. External catheter use and urinary tract infections among incontinent



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27.

28. 29.

30.

31.

32. 33.

34. 35. 36.

37. 38.

39.

40.

41.

male nursing home patients. .I Am Geriatr Sot 1987; 351063-70. Nicolle LE, Henderson E, Bjornson J, McIntyre M, Harding GKM, MacDonell JA. The association of bacteriuria with resident characteristics and survival in elderly institutionalized men. Ann Intern Med 1987; 106:682-6. Warren JW, Steinberg L, Hebel JR, Tenney JH. The prevalence of urethral catheterization in Maryland nursing homes. Arch Intern Med 1989;149:1535-7. Kunin CM, Chin QF, Chambers S. Morbidity and mortality associated with indwelling urinary catheters in elderly patients in a nursing home-confounding due to the presence of associated diseases. J Am Geriatr Sot 1987;35:1001-6. Gleckman R, Blagg N, Hibert D, et al. Catheter-related urosepsis in the elderly: a prospective study of community-derived infections. J Am Geriatr Sot 1982;30:255-7. Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;146:719-23. Sherman FT, Tucci V, Libow LS, Isenberg HD. Nosocomial urinary tract infections in a skilled nursing facility. J Am Geriatr Sot 1980;28:456-61. Daly PB, Smith PW, Rusnak PC, Holmquist H. Nursing home urinary catheter bacteria: isolates and antibiotic sensitivities. Abstract at 15th Annual APIC Educational Conference, Dallas, May, 1988. Nicolle LE. Urine cultures and long-term indwelling catheters [editorial]. Arch Intern Med 1985;145: 1794-5. Breitenbucher RB. Bacterial changes in the urine samples of patients with long-term indwelling catheters. Arch Intern Med 1984;144:1585-8. Nicolle LE, Mayhew WJ. Bryan L. Prospective randomized comparison of therapy and no therapy of asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987;83:27-33. Wong ES, Hooten TM. Guideline for prevention of catheter-associated urinary tract infections. Infect Control 1981;2:125-30. Peterson PK, Stein D, Guay DRP, et al. Prospective study of lower respiratory tract infections in an extended-care nursing home program: potential role of oral ciprofloxacin. Am J Med 1988;85: 164-71. Bentley DW, Ha K, Mamot K, et al. Pneumococcal vaccine in the institutionalized elderly: design of a nonrandomized trial and preliminary results. Rev Infect Dis 1981;3(suppl):s71-~81. Bolan G, Broome CV, Facklam RR, Plikaytis BD, Fraser DW, Schlech WF. Pneumococcal vaccine efficacy in selected populations in the United States. Ann Intern Med 1986;104:1-6. Sims RV, Steinmann WC, McConville JH, King LR,

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54. 55.

56.

57.

58.


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Zwick WC, Schwartz JS. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653-7. LaForce FM. Pneumoccccal vaccine: an emerging consensus. Ann Intern Med 1988;108:757-9. Centers for Disease Control. Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8, 73-6. Marrie TJ, Durant H, Kwan C. Nursing home-acquired pneumonia: a case control study. J Am Geriatr Sot 1986;34:697-702. Garvie DC, Gray J. Outbreak of respiratory syncytial virus infection in the elderly. Br Med J 1980;281: 1253-4. Simmons BP, Wong ES: Guideline for prevention of nosocomial pneumonia. Infect Control 1982;3: 327-37. Centers for Disease Control. Prevention and control of influenza. Part I. Vaccines. MMWR 1989;38:297-98, 303-l 1. Hall WN, Goodman RA, Noble CR, Kendal AP, Steece RS. An outbreak of influenza B in an elderly population. J Infect Dis 1981;144:297-302. Goodman RA, Orenstein WA, Munro TF, Smith SC, Sikes RK. Impact of influenza A in a nursing home. JAMA 1982;247:1451-3. Van Voris LP, Belshe RB, Shaffer JL. Nosocomial influenza B virus infection in the elderly. Ann Intern Med 1982;96:153-8. Centers for Disease Control. Outbreaks of influenza among nursing home residents-Connecticut, United States. MMWR 1985;34:478-82. Meiklejohn G, Hall H. Unusual outbreak of influenza A in a Wyoming nursing home. J Am Geriatr Sot 1987;35:742-6. Patriarca PA, Weber JA, Parker RA, et al. Efficacy of influenza vaccine in nursing homes: reduction in illness and complications during an influenza A (H3N2) epidemic. JAMA 1985;253:1136-9. Saah AJ, Neufeld R, Rodstein M, et al. Influenza vaccine and pneumonia mortality in a nursing home population. Arch Intern Med 1986;146:2353-7. Arden NH, Patriarca PA, Fasano MB, et al. The roles of vaccination and amantadine prophylaxis in controlling an outbreak of influenza A (H3N2) in a nursing home. Arch Intern Med 1988;148:865-8. Gross PA, Quinnan GV, Rodstein M, et al. Association of influenza immunization with reduction in mortality in an elderly population. Arch Intern Med 1988; 148:562-S. Patriarca PA, Arden NH, Koplan JP, Goodman RA. Prevention and control of type A influenza infection in nursing homes: benefits and costs of four approaches using vaccinations and amantadine. Ann Intern Med 1987;107:732-40. Arden NH, Kendal AP, Patriarca PA. Managing an influenza vaccination program in the nursing home. US


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Department of Health and Human Services, Centers for Disease Control, 1987. 59. Stead WW. Tuberculosis among elderly persons: an outbreak in a nursing home. Ann Intern Med 1981; 94:606-10. 60. Stead WW, Lofgren JP, Warren E, Thomas C. Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. N Engl J Med 1985; 312:1483-7. 6 1. Rudd A. Tuberculosis in a geriatric unit. J Am Geriatr Sot 1985;33:566-9. 62. Narain JP, Lofgren JP, Warren E, Stead WW. Epidemic tuberculosis in a nursing home: a retrospective cohort study. J Am Geriatr Sot 1985;33:258-63. 63. Price LE, Rutala WA. Tuberculosis screening in the long-term care setting. Infect Control 1987;8:353-6. 64. Stead WW. Control of tuberculosis in institutions. Chest 1979;76(suppl):797-800. 65. Keams TJ, Cole CH, Farer LS, et al. Public health issues in control of tuberculosis; surveillance techniques and the role of health care providers (a national consensus statement). Chest 1985;87(suppl): 135-8. 66. Bentley DW. Tuberculosis in long-term care facilities. Infect Control Hosp Epidemiol 1990; 11:42-6. 67. McGowan GE Jr. The booster effect-a problem for surveillance of tuberculosis in hospital employees. Infect Control 1980; 1: 147-9. 68. Shepard MA, Parker D, DeClercque N. The underreporting of pressure sores in patients transferred between hospital and nursing home. J Am Geriatr Sot 1987;35:159-60. 69. Bryan CS, Dew CE, Reynolds KL. Bacteremia associated with decubitus ulcers. Arch Intern Med 1983; 143:2093-s. 70. Reuler JB, Cooney TG. The pressure sore: pathophysiology and principles of management. Ann Intern Med 1981;94:661-6. 71. Fowler E. Pressure sores: a deadly nuisance. J Geronto1 Nurs 1982;8:680-5. 72. Centers for Disease Control. Scabies in health-care facilities-Iowa. MMWR 1988;37:178-9. 73. Burkhart CG. Scabies: an epidemiologic reassessment. Ann Intern Med 1983;98:498-503. 74. Rasmussen JE. Advances in the treatment of head and pubic lice. Drug Ther 1983;13:185-92. 75. Ryan CA, Tauxe RV, Hosek GW, et al. Escherichia co/i 0157:H7 diarrhea in a nursing home: clinical, epidemiological, and pathological findings. J Infect Dis 1986;154:631-8. 76. Carter AO, Broczyk AA, Carlson JAK, et al. A severe outbreak of Escherichia coli 0157:H7-associated hemorrhagic colitis in a nursing home. N Engl J Med 1987;317:1496-500. 77. Bender BS, Laughon BE, Gaydos C, et al. Is Clostridium dificile endemic in chronic-care facilities? Lancet 1986;2:11-3.

78.

79.

80.

81. 82.

83.

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.


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White KE, Hedberg CW, Edmonson LM, Jones DBW, Gsterholm MT, MacDonald KL. An outbreak of giardiasis in a nursing home with evidence for multiple modes of transmission. J Infect Dis 1989;160:298304. Setia U, Serventi I, Lorenz P. Bacteremia in a longterm care facility-spectrum and mortality. Arch Intern Med 1984;144:1633-5. Simmons BP, Hooton TM, Wong ES, Allen JR. Guidelines for prevention of intravascular infections. Infect Control 1982;3:61-72. Centers for Disease Control. Surveillance for epidemics-United States. MMWR 1989;38:694-6. Baine WB, Gangarosa EJ, Bennett JV, Barker WH Jr. Institutional salmonellosis. J Infect Dis 1973;128:35760. Ruben FL, Norden CW, Heisler B, Korica Y. An outbreak of Streptococcuspyogems infections in a nursing home. Ann Intern Med 1984;101:494-6. Starch GA, Radcliff JL, Meyer PL, Hinrichs JH. Methicillin-resistant Staphylococcus aureus in a nursing home. Infect Control 1987;8:24-9. Hsu CCS, Macaluso CP, Special L, Hubble RH. High rate of methicillin-resistance of Staphy2ococcus aureus isolated from hospitalized nursing home patients. Arch Intern Med 1988;140:569-70. Thomas JC, Bridge J, Waterman S, Vogt J, Kilman L, Hancock G. Transmission and control of methicillinresistant StuphyZococcus aureus in a skilled nursing facility. Infect Control Hosp Epidemiol 1989; 10: 10610. Bjork DT, Pelletier LL, Tight RR. Urinary tract infections with antibiotic resistant organisms in catheterized nursing home patients. Infect Control 1984;s: 173-6. Gaynes RP, Weinstein RA, Chamberlin W, Kabins SA. Antibiotic-resistant flora in nursing home patients admitted to the hospital. Arch Intern Med 1985;145: 1804-7. Shlaes DM, Lehman MH, Currie-McCumber CA, Kim CH, Floyd R. Prevalence of colonization with antibiotic resistant gram-negative bacilli in a nursing home care unit: the importance of cross-colonization as documented by plasmid analysis. Infect Control 1986;7:538-45. Crossley KB, Irvine P, Kaszar DJ, Loewenson RB. Infection control practices in Minnesota nursing homes. JAMA 1985;254:2918-21. Khabbaz RF, Tenney JH. Infection control in Maryland nursing homes. Infect Control Hosp Epidemiol 1988;9:159-62. US Department of Health and Human Services, Health Care Financing Administration. Medicare and Medicaid requirements for long term care facilities. Fed Register 1989;54:5316-73. Health Care Financing Administration. Long Term Care Survey Process Training Manual, 1986. Pub-


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101. 102.

Committee reports

lished by the National Technical Information Services. Occupational Safety and Health Administration. Occupational exposure to bloodbome pathogens. Fed Register 1989;54:23042-39. Guidelines for construction and equipment of hospital and medical facilities. Washington DC: American Institute of Architects, 1987. Long-term care standards manual. Chicago: Joint Commission on Accreditation of Healthcare Organizations, 1988. American Health Care Association. Infection control in long-term care facilities-an administrative guide, Washington DC, 1983. Smith PW. Infection control in long-term care facilities. 1st ed. New York: John Wiley, 1984. Harris J, Dryer P, Mello P, Connelly K. Evaluation of infection control practices in nursing homes. Abstract 1303 at the 27th Interscience Conference on Antimicrobial Agents and Chemotherapy, October, 1987, New York. Vlahov D, Tenney JH, Cervion KW, Shamer DK. Routine surveillance for infections in nursing homes: experience at two facilities. Am J Infect Control 1987; 15:47-53. Gamer JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128-40. Smith PW. Consensus conference on nosocomial infections in long-term care facilities. AM J INFECT CONTROL 1987;15:97-100.

103. McGeer A and the Canadian Consensus group. Evaluation of new criteria for infections in Canadian long term care facilities, 1990. 104. Association for Practitioners in Infection Control. Long term care in the APIC curriculum for infection control practice. Iowa: Kendall Hunt Publishing Co., 1988;111:1329-89. 105. Centers for Disease Control. Introduction to applied epidemiology, August 1983. 106. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983;4:245-325. 107. Haley RW, Garner JS, Simmons BP. A new approach to the isolation of hospitalized patients with infectious diseases: alternative systems. J Hosp Infect 1985;6: 128-39. 108. Centers for Disease Control. Recommendations for prevention of HIV transmission in health care settings. MMWR 1987;36:18-188. 109. Centers for Disease Control. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodbome pathogens in health-care settings. MMWR 1988;37:377-87. 110. Lynch P, Cummings MJ, Roberts PL, Herriott MJ, Yates B, Stamm WE. Implementing and evaluating a

INFECTION

111. 112.

113. 114. 115.

117. 118.

119. 120. 121.

122. 123.

124. 125.

126. 127.


of

system of generic infection precautions: body substance isolation. AM J INFECT CONTROL 1990;18:1-12. Larson E. Guideline for use of topical antimicrobial agents. AM J INFECT CONTROL 1988;16:253-66. Garner JS, Favero MS. Guideline for handwashing and hospital environmental control. Infect Control 1986; 7:231-43. Irvine PW, VanBuren N, Crossley K. Causes for hospitalization of nursing home residents: the role of infection. J Am Geriatr Sot 1984;32:103-8. Williams WW. Guideline for infection control in hospital personnel. Infect Control 1983;327-49. LeClair SM, Schicker JM, Duthie EH Jr, Hoffman RG, Franson TR. Survey of nursing personnel attitudes toward infections and their control in the elderly. AM 3 INFECT

116.

Journal CONTROL

CONTROL

1988;16:159-66.

Rusnak PG, Daly PB, Smith PW. Evaluation of a course for nursing home infection control practitioners. Abstract, 15th Annual APIC Educational Conference, Dallas, May, 1988. Smith PW, Holmquist HR. Infections in the elderly. Part III. Antibiotic usage in nursing homes. Hosp Ther 1988;13:42-55. Jones SR, Parker DF, Liebow ES, Kimbrough RC III, Frear RS. Appropriateness of antibiotic therapy in long-term care facilities. Am J Med 1987;83:499502. Zimmer JG, Bentley DW, Valenti WM. Watson NM. Systemic antibiotic use in nursing homes: a quality assessment. J Am Geriatr Sot 1986;34:703-10. Weinstein RA. Resistant bacteria and infection control in the nursing home and hospital. Bull NY Acad Med 1987;63:337-44. Department of Labor Joint Advisory Notice. Protection against occupational exposure to hepatitis B virus and human immunodeficiency virus. Fed Register 52:41818-24, 1987. American Health Care Association. AIDS and the nursing home patient. Washington DC: The Health Education Resource Organization, 1987:1-109. Gwartney DL. Daly PB, Smith PW. Four state survey evaluation of AIDS attitudes and policies in long term care facilities. University of Nebraska Student Research Form, 1988. Association for Practitioners in Infection Control. The APIC curriculum for infection control practice. Vols, I and II (1983) Vol. III (1988). Wreed VD, Rusnak PG. Regulations, policies and procedures. In: Smith PW. Infection control in long term care facilities. 1st ed. New York: John Wiley, 1984. Joint Committee on Health Care Laundry Guidelines. Guidelines for health care linen service, Rev. Chicago, 1988. Centers for Disease Control. Disinfection of hydrotherapy pools and tanks, 1972.


Volume October

128. 129.

130.

131.

18 Number 1990

5

Committee

reports

53A

APPENDIX

Rutala WA. APIC guideline for selection and use of disinfectants. AM J INFECT CONTROL 1990;18:99-117. Rutala WA, Odette RL, Samsa GP. Management of infectious waste by US hospitals. JAMA 1989;262: 163571. Environmental Protection Agency. Standards for the tracking and management of medical waste. Fed Register 1989;54: 12326-95. Crede W, Hierholzer WJ. Linking hospital epidemiology and quality asurance: seasoned concepts in a new role. Infect Control Hosp Epidemiol 1988;9:42-4.

Definitions of Infections for Surveillance in Long Term Care Facilitier=Report of a consensus conference, Toronto, Canada, 1990 (Corresponding author: Dr. A. McGeer,

Department of Microbiology, pital, Toronto, Canada)

Mount

Sinai Hos-

SITE: UPPER RESPIRATORY COMMON

COLD SYNDROMES

Criteria

Conditions Symptoms must be acute sonal or medication)

TWO or more of: 0 running nose or sneezing 0 stuffy nose (i.e., nasal congestion) l sore throat or hoarseness or difficulty swallowing l dry cough l new swollen or tender glands in the neck (i.e., cervical lymphadenopathy)

and not related

to allergy

(sea-

Comments Fever

not required,

but does

not exclude

diagnosis

EAR Criteria Diagnosis Any

new

by a physician drainage

from

of any ear infection or one of both ears

MOUTH (AND PERLORAL) (includes oral candldlasis) Criteria Diagnosis

by physician

or dentist

of any

mouth

infection

SINUSITIS Criteria Diagnosis

by a physician

This draft APIC document is being made available only. It is not to be quoted, reproduced, circulated., to be considered either “final” or “published.”


American

54A

Committee reports

INFECTION

INFl.UENZA=LIKE

Journal CONTROL

ILLNESS Conditions

Criteria

Symptoms must be acute and Must be during influenza season (in Ontario, Nov-Apr)

Fever and THREE or more of: 0 chills l headache or eye pain l myalgias (muscular aching) 0 malaise or loss of appetite l sore throat l dry cough

Comment When this definition is met, it takes precedence others

over

SITE: LOWER RESPIRATORY PNEUMONIA Criteria Interpretation by a radiologist of a chest x-ray as demonstrating pneumonia, probable pneumonia, or presence of an infiltrate with a compatible clinical syndrome

OTHER LOWER RESPIRATORY Criteria THREE or more of: l new or increased cough l new or increased sputum production 0 fever l pleuritic chest pain l new physical findings on chest pain (rales, rhonchi, wheezes, bronchial breathing) 0 one or more of: -new shortness of breath -increased respiratory rate (>25/min) -change in mental status -change in functional status

Conditions Symptoms must be acute and Eithernochestx-raydone,orx-raydoesnotmeettheabove criteria for pneumonia



of

Volume 18 Number October 1990

SITE:

5

URINARY

Committee

Conditions

A. RESIDENT WITHOUT CATHETER THREE or more of: l fever or chills 0 new burning pain on urinating, or frequency or urgency l flank or suprapubic pain or tenderness 0 change in character of urine (visual, or by smell, or by lab testing) l change in mental or functional status, including new or worse incontinence B. RESIDENT WITH CATHETER TWO or more of: l fever or chills l flank or suprapubic pain or tenderness 0 change in character of urine 0 change in mental or functional status

GASTROINTESTINAL

Symptoms

must

be acute and

Ifanappropriatelycollectedand taken and if the resident time, then that culture

processed urineculturewas was not receiving antibiotics at the result must be positive

For the catheterized present

resident,

no other

source

of fever

Comment Asymptomatic

bacteriuria

may

be recorded

separately

TRACT GASTROENTERITIS

Criteria

Conditions

THREE or more loose or watery stools above what is normal for the resident within a 24 hour period or THREE or more episodes of vomiting within a 24 hour period or Stool culture positive for a pathogen (Salmonella, Shigella, Campylobacter species, or Clostricfium difficile) with a compatible clinical syndrome

Forthefirsttwocriteria, infectious cause; e.g., for diarrhea: cation; for vomiting: disease

SITE:

551

TRACT

Criteria

SITE:

reports

theremustbenoevidenceofanonlaxative, change

change in tube feeds or mediin medication, peptic ulcer

SKIN CELLULiTIS/SOFT

TISSUE/WOUND

Criteria Pus is present

at a wound,

or more of: fever (and, at the site of infection, l heat l redness 0 swelling l tenderness l serous drainage

skin, or

or soft tissue

site

FOUR l

new

or increasing:)



is

American

56A

Committee reports

INFECTION

FUNGAL

Journal CONTROL

SKIN INFECTION

Criteria

Conditions

Maculopapular physician

rash

No evidence of a non-infectious to new medication)

and or laboratory

diagnosis

cause

(e.g.,

allergy

confirmation

HERPES SIMPLEX

(cold sores) or HERPES ZOSTER (shingles)

Criteria Vesicular physician

rash and or laboratory

diagnosis

confirmation

SCABIES Criteria

Conditions

Maculopapular

and/or

itching

rash

If there evidence

and physician

diagnosis

or laboratory

is no laboratory confirmation, of a non-infectious cause

then there

must

be no

confirmation

SITE: EYE CONJUNCTIVITIS Conditions

Criteria Pus appearing “pink eye” pain), present

from

one or both

(i.e., conjunctival for 224 hours

eyes

redness,

for 224 often

with

hours itching

Noevidenceoftrauma(e.g.,foreign cause

body)orallergyasa

or

SITE: GENERALIZED PRIMARY

BLOODSTREAM Condltion

Criteria TWO or more organism

blood

cultures

are documented

with the same

Organism in blood culture othersite(bloodstreaminfectionwould ondary)

is not related to infection at anthenclassifiedassec-

or Asingle blood culture is documented with anorganism thought not to be a contaminant, and ONE of the following: l fever or new hypothermia l drop in systolic blood pressure of >30 mm Hg over baseline l change in mental or functional status

UNEXPLAINED

FEBRILE

EPISODE

Crlterla

Condition

Documentation in the medical record of fever on 2 or more occasions at least 12 hours apart in any three day period

No known infectious (e.g., infection at any


or noninfectious site, medication)

cause

for the fever


of

Volume

18 Number

October

1990

5

Committee

reports

57A

GLOSSARY CHANGE

IN CHARACTER OF URINE:

CHANGE

IN FUNCTIONAL STATUS:

CHANGE

IN MENTAL COMPATIBLE

DIAGNOSIS

STATUS:

CLINICAL SYNDROME:

BY A PHYSICIAN:

EAR

INFECTION:

FEVER: HYPOTHERMIA: LABORATORY

NEW

CONFIRMATION:

PHYSICAL

FINDINGS ON CHEST EXAM: ORGANISM THOUGHT TO BE A CONTAMINANT (in blood culture):

Any significant change in the gross (e.g., new bloody urine, foul smell, or amount of . sediment) or microscopic (new pyuria, or microscopic haematuria) character of the urine. For microscopic changes, this means that the results of a previous urinalysis must be on the chart. There is no time limit on when the previous urinalysis may have been done. A significant change in the resident’s ability or willingness to carry out activities of daily living. For instance, new incontinence, new inability to walk to the dining room, or increased difficulty in transfers would all be recorded as change in functional status. A significant change in the residents cognitive function: for most residents, this will mean an increased level of confusion (e.g., new non-recognition of nurses). An acute illness with symptoms related to the relevant system (respiratory or gastrointestinal). In general, the symptoms will be some of those included in the definitions for either lower respiratory infection or gastroenteritis, but the criteria for the infection need not be met. Requires one of: a written note by a physician specifying diagnosis, a nursing note specifying that a diagnosis was made by a physician, or a verbal report from either a physician or nurse that a specific diagnosis has been made. Includes infections of the external ear (otitis externa), middle ear (otitis media), or internal ear (otitis interna, labyrinthitis, vestibular neuronitis). A single temperature, taken by any route, of ~38” C. A temperature which is below 34.5’ C, or which does not register on the thermometer being used. With respect to skin infections, acceptable lab confirmation consists of: 1. Candida: positive culture from swab 2. Other fungi: positive culture from scraping 3. Herpes zoster or simplex: positive electron microscopic (EM) findings from scraping, or positive culture of scraping or swab (note that EM cannot distinguish different species of Herpes) 4. Scabies: Positive microscopic exam of scrapings New findings on examination of the chest with a stethoscope which suggest pneumonia: i.e., rales (crackles), rhonchi (wheezes), or bronchial breathing. Organisms which are common skin flora may contaminate blood cultures, and a single blood culture positive for one of these may be non-significant

MEDICAL TERMS CONJUNCTIVA: FLANK:

LYMPHADENOPATHY: MACULOPAPULAR:

PLEURITIC

MALAISE: PATHOGEN: CHEST PAIN: PURULENT: SEROUS: SUPRAPUBIC: VESICULAR:

Mucous membrane covering the eyeball. Side of the body, below the rib cage and above the hip (the area in which pain is usually felt in upper urinary tract infections, referred to as the “costovertebral angle”, is a relatively posterior area of the flank just below the ribs and extending from the side nearly to the backbone). Enlargement of lymph glands. Applied to a rash characterized by abnormally coloured (usually red) areas of skin, of varying size, which may be either flat or slightly raised. A feeling of generalized discomfort or uneasiness, or being “out-of sorts.” A microorganism capable of causing disease. Pain caused by inflammation of the pleura (lung lining): a sharp pain felt at any site over the rib-cage, which is brought on or made much worse by deep breathing. Containing the by-products of inflammation (pus). With watery consistency (as opposed to purulent). Above the pubic arch (i.e., the area of the bladder, in the central lower area of the abdomen. Applied to a rash characterized by blister-like lesions (i.e., localized areas to elevated skin, usually only a few mm in size, containing a watery substance).



APIC guideline for infection prevention and control in the long-term care facility.

Infection prevention and control guideline for cystic fibrosis: 2013 update.

Impact of Infection Prevention and Control Initiatives on Acute Respiratory Infections in a Pediatric Long-Term Care Facility.

Impact on knowledge and practice of a multiregional long-term care facility infection control training program.

Association for Practitioners in Infection Control and the American Journal of Infection Control after twenty years: a review.

State regulations governing infection control issues in long-term care.

Infection prevention and control practices in pediatric long-term care facilities.

Infection prevention and control.

Middle East Respiratory Syndrome Infection Control and Prevention Guideline for Healthcare Facilities.

The outcome competency framework for practitioners in infection prevention and control: use of the outcome logic model for evaluation.

Infection control in intensive care.

Infection in long term care facility in the kingdom of Bahrain.

Definitions of infection for surveillance in long-term care facilities.

Control of the spread of viruses in a long-term care facility using hygiene protocols.

Infection control in the intensive care unit.

Survey of C. difficile-Specific Infection Control Policies in Local Long-Term Care Facilities.

Infection control in a Third World burn facility.

Study of the definition of nosocomial infections (SDNI). Research Committee of the Association for Practitioners in Infection Control.

Design and dissemination of a multiregional long-term care infection control training program.

Infection Prevention and Control at Home.

Two years of infection surveillance in a geriatric long-term care facility.

Infection Control Nurses Association' to Infection Prevention Society: 10 years on.

Infection control in equine critical care settings.

Infection Control in Health Care Facilities.