Examining Contact Precautions in Nursing Homes

In her presentation on March 30, 2017, at the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, Robin Jump, MD, PhD, assistant professor of medicine in the Division of Infectious Disease and HIV Medicine at Case Western Reserve University, physician-scientist at the Geriatric Research, Education and Clinical Center (GRECC), and the Louis Stokes Cleveland Veterans Affairs Medical Center, talked about the challenges associated with isolation precautions in long-term care settings, specifically nursing homes.

There are more than 15,500 nursing home facilities across the country, which care for about 1.4 million individuals daily, and 4.1 million annually. About 15% of those living in nursing homes are under 65 years of age, and approximately 40% are over 85 years of age. More than half of these individuals have dementia, and 5% to 25% are living with some sort of indwelling medical device.

“The other thing that’s special about this population,” said Dr. Jump, “is that they’re highly dependent on help for ADLs [Activities of Daily Living], bathing dressing, toileting, eating, and mobility.” More often than not, “This requires two people to get involved to do this, and that also means a lot more contact.” And the people who end up doing the “literal heavy lifting,” as Dr. Jump put it, is healthcare workers, nurses, and front-line staff.

One of the main challenges of isolation precautions in long-term care, according to Dr. Jump, is finding that “balance between personal rights and public safety.” For these patients, the facility is their home; it’s where they live. “We can’t tell someone that they must stay in their room for 6 weeks at a time. We encourage social interactions and recreation, there is the right to privacy even though we have two beds in a room a lot of the time, and there is often sexuality.”

However, since nursing homes can be reservoirs for multidrug-resistant organisms (MDROs), isolation is sometimes needed. In order to quality for reimbursement from the Centers for Medicare and Medicaid Services, nursing homes must submit Minimum Data Set (MDS) reports on all residents. In an analysis, resident MDS reports from over a 15-month period were examined. “Of the 4 million residents who were included in the study, 5% had an MDRO infection. We don’t know how many were actually colonized. The infection rate was truly the tip of the iceberg here.” Of the residents who were actually infected, 57% were found to have acquired infection from a nursing home, whereas 41% became infected at a hospital.

Dr. Jump drew on several different studies to estimate MDRO colonization rates in nursing homes. Colonization prevalence for methicillin-resistant Staphylococcus aureus (MRSA) “may exceed 50%,” and approximately 25% of infected individuals may have acquired infection at the nursing homes. Prevalence of fluoroquinolone-resistant gram-negatives is “upwards of 50%,” with 17% of individuals having Extended Spectrum Beta-Lactamase (ESBL) bacteria, and 1% having carbapenem-resistent Enterobacteriaceae, “which is really high in my opinion,” noted Dr. Jump. In terms of Clostridium difficile, Dr. Jump estimates that “about 15% of nursing home residents may be asymptomatic carriers.”

Risk factors that contribute to infection with MDROs in nursing homes include “recent antibiotic exposure [within the past 4 months], dependence for assistance with ADLs (which means contact with healthcare workers), and, also, indwelling medical devices, as well as decubitus ulcers, other wounds, and urinary and fecal incontinence.”

In a study published in Infection Control and Hospital Epidemiology, a SHEA journal, in 2015, researchers investigated the frequency at which nursing home residents transfer MRSA (which Dr. Jump said was “a good surrogate in long-term care for other MDRO transmission”) to healthcare workers’ gowns and gloves during routine care. The researchers found that gloves were contaminated at a higher rate than gowns, and that residents with skin breakdown were more likely to transmit MRSA. “But here’s the thing that always fascinated me about this study. They looked at what the high-risk activities that healthcare workers were doing that were most likely to have them wind up with MRSA on their gowns and gloves: dressing, transferring, hygiene (brushing hair, brushing teeth), changing linens (which is not one I would have thought about), and toileting. So, there are a lot of things that are happening with long-term care residents that would lead to the acquisition of MRSA on the healthcare worker.”

Dr. Jump then went on to break down recommended isolation precautions based on syndrome. In the event of an outbreak of gastroenteritis or norovirus, healthcare personnel working with nursing home residents who have syndrome-specific symptoms should wear gowns, masks, and gloves in most cases; the same measures should be taken with outbreaks of respiratory infections. Most nursing home workers tend to take Respiratory Syncytial Virus (RSV) more seriously than, for example, a cold, and there tends to be much more compliance on precautions from healthcare workers, especially droplet precautions (which require the use of masks). “And finally, scabies; that gets everyone’s attention, and people are really good about wearing gowns and gloves when it comes to scabies.”

Of course, one of the most important infections when it comes to precautions in the nursing home setting is C. difficile. Since spores tend to stay around for longer periods because they’re much more difficult to get rid of, they remain a source of infection transmission, even after symptoms resolve. “As it turns out, the residents themselves will also remain a source of transmission long after symptoms have resolved, because they still have spores on their skin.” Therefore, nursing homes should institute contact precautions early, and use sporicidal agents to disinfect rooms. “In long-term care it makes sense to continue isolation and contact precautions beyond 48 hours to diarrhea resolution, and to keep going for a longer period of time.”

On the other hand, isolation precautions for specific pathogens, such as MRSA, VRE, ESBLs, CRE, is different. The duration of colonization is unknown (could be several months). Likewise, the risk of colonization turning into infection is also unclear. “We don’t have decolonization protocols that we know will work past the end of the decolonization protocol. For adults, and for long-term care, in general, it seems that after someone has been decolonized, they are at high risk of getting decolonized.” Therefore, what may be effective for one week after treatment cessation, may not be effective the second week thereafter.

“So, is there a better way to think about this in long-term care? Thankfully, the answer is ‘yes,’” said Dr. Jump before discussing a controlled targeted infection prevention study.

This study focused on nursing home residents with either urinary catheters or feeding tubes. Healthcare workers assisting nursing home residents were required to practice proper hand hygiene before and after handling the resident, wear gowns and gloves during morning and evening care, and during device care. This study also required “weekly intense meetings” for staff education and active surveillance for MDROs.

More than 6,000 samples were collected from the 418 residents enrolled in the study. “Through this intensive intervention, focusing not on people with a bacterial syndrome, but on people with devices, regardless of what they may or may not be colonized with, [the researchers] were able to decrease MDRO prevalence (rate ratio, 0.77; 95% CI, 0.62-0.94). They decreased the rate of new MRSA acquisitions (rate ratio, 0.78; 95% CI, 0.64-0.96), they decreased the risk of a first CAUTI [catheter-associated urinary tract infections], and of all CAUTIs, and this is phenomenal.” According to the study, “Hazard ratios for the first and all (including recurrent) clinically defined CAUTIs was 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft tissue infections.”

Dr. Jump said, “It’s much easier to not think about the alphabet soup of what someone might have, but [rather] to know that they have a wound, or they have a urinary catheter, or they have some kind of central line, and how to act with that device, or how to respond to that device.”

In terms of contact precautions for in-room care, on the other hand, Dr. Jump recommends, practicing proper hand hygiene and wearing gowns and gloves prior to room entry. Upon exiting a room, healthcare workers are to remove these gowns and gloves, and then do hand hygiene again. Healthcare workers should also use single-use equipment in long-term care when feasible and should try to dedicate equipment to individual residents when possible. Cleaning and disinfecting equipment that cannot be individualized is very important so as to not transmit infections between patients. All personal protective equipment should be sufficiently stocked at the site of care. “So the burden here falls on healthcare workers,” said Dr. Jump.

However, that doesn’t mean that the residents themselves shouldn’t practice hand hygiene. Upon leaving their rooms, residents must be clean, contained (bandaged or dressed), and cooperative.

Dr. Jump’s ultimate take home message was to find a good balance between resident safety and individual liberty, while keeping in mind that any resident with an MDRO is a reservoir for that organism. “Activities most linked to transmission involve healthcare workers…not resident-to-resident. For MDROs, transmission-based precautions based on resident risk factors may be most rational, feasible strategy.”

DISCLOSURES:

Dr. Jump has no direct conflicts of interest related to this presentation.

Dr. Jump has current research support from Steris. She has previously consulted for GOJO and Pfizer and has previous grant support from Pfizer, Merck and ViroPharma.

The opinions presented herein are Dr. Jump's and do not represent those of the Veterans Affairs system or the federal government.

SOURCE:

SHEA Spring 2017 Conference

PRESENTATION:

Isolating the “Right” Person: Challenges to Isolation Precautions in Nursing Homes