AHRQ Safety Program for Long-Term Care: HAIs/CAUTI

Clean Equipment and Environment:Knowledge and Practice

Training Module # 2 for the LTC Core Team

Current as of July 2015

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Learning Objectives

After completing this session, facility team leaders and core team members will be able to:

• Describe the chain of infection and identify key strategies to break the chain

• Explain catheter care and maintenance strategies that facility staff can use to prevent residents from acquiring a catheter-associated urinary tract infection (or CAUTI)

• Explain the role of the environment as a place where pathogens can become a source of infection for residents and staff

• Summarize strategies to improve cleaning and disinfecting practices using the training materials for all facility staff

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Protecting Residents Against Infection

The Chain of Transmission: Six Links

Chain of

Infection

Infectious Agent

(Viruses or Bacteria)

Resident (Reservoirs)

Exit Resident(Portal of Exit)

Mode of Transmission

Entry of New

Resident(Entry Portal)

New Resident

(Susceptible Host)

Each link stands for something (or someone) that helps pass on an infection.

An infection can be passed from one person to another person as long as the links of the

chain are joined together.

Siedlaczek G. SJMHS

Breaking the Chain of Infection:The Role of LTC Facility Staff

The Chain of Transmission: Six Links

Chain of

Infection

Infectious Agent

(Viruses or Bacteria)

Resident (Reservoirs)

Exit Resident(Portal of Exit)

Mode of Transmission

Entry of New

Resident(Entry Portal)

New Resident

(Susceptible Host)

How Can HCW Break the Chain of Infection?

Education• Hand hygiene • Gloves• Clean rooms• Disinfected surfaces• Proper medical device care and

maintenance

Ensure residents have:• Good personal hygiene• Covered cuts/wounds• Isolation when necessary• No unnecessary antibiotics• Proper waste disposal

Siedlaczek G. SJMHS4

The Usual Bacteria Suspects:Multidrug-resistant Organisms (MDROs) Common in LTC

Residents with an indwelling catheter are more likely tohave one of these MDROs

Mody L, et al. Clin Infect Dis 2011;52:654-515

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Front-line Staff Training Recap

• Microbes can enter an indwelling urinary catheter’s closed system during insertion, care and maintenance of the catheter and drainage bag

• Conduct routine hygiene of the resident and remember hand hygiene

• Stabilization devices reduce irritation that may increase the risk for serious infection

• Urine measuring devices should never be shared and should be cleaned and dried between use

Entry Pathways for Microbes

• Aseptic technique plays a key role in preventing catheter or drainage bag contamination

• Routine hygiene is important

• Disinfect the port before obtaining a urine culture

• Check catheter, tubing and drainage bag for disconnection, kinks

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8

Hand Hygiene

Good Better Best

Plain soap Antimicrobial soap

Alcohol-based hand rub

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Protecting Residents Against Infection: Role of Clean Equipment and Environment

Factors associated with increased risk of infection in residents include1:

Lower level of cleanliness Higher frequency of odors High turnover rate of nurses Fewer certified nurses’ aides/100 beds

Zimmerman S, et al. JAGS 2002;50:1987-95.

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MRSA and the Environment

• MRSA is a growing problem in LTC

• A study of 10 long-term care facilities found MRSA present on 16% of surfaces tested

• MRSA was more often present in residents’ rooms that were cleaned less frequently and for less time

Murphy CR, et al. JAGS 2012;60:1012-18

Methicillin-resistant Staphylococcus aureus

MRSA

Survival of Select Microbes onEnvironmental Surfaces

Microorganism Survival on Environmental Surfaces

BacteriaClostridium difficile (C. diff) spore > 1 yr. Vancomycin-resistant Enterococci (VRE)

5 days – 4 months

Methicillin-resistant Staphylococcus aureus (MRSA)

7 days – 7 months

VirusesHepatitis B virus (HBV) > 1 weekHuman immunodeficiency virus (HIV)

3 – 4 days

Norovirus 8 hrs – 7 days

11Kramer A. BMC ID 2006; McFarland L, et al. AJIC 2007

MDROs Can Hang Around

represents positive VRE culture sites – ready for next patient?

Vancomycin-resistant Enterococci (VRE) detected on surfaces indicated – cultures done AFTER discharge cleaning/disinfection

Duckro AN, et al. Arch Intern Med 2005;165:302-7 12

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Baseline 2 months 6 months0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

27%

78%68%

% Removed

% Removed

Is It Really Clean?Experience With Fluorescent Marker in LTC

Applegate D, et al. Evaluation of environmental cleaning in LTC Facilities, ID Week 2012

Disinfection of the Environment & Equipment

Why is it important to disinfect surfaces in the LTC facility?• Surfaces that are touched frequently increase the

chance that microorganisms could be spread to residents or staff

• While surfaces may look clean, pathogens may be lurking

What can LTC front-line staff do?• Cleaning/disinfection offers extra margin of safety• Disinfectant kills bacteria and viruses that can’t be

seen• Focus disinfection on surfaces that are touched a lot

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Let’s Chat!

What Role Does Leadership Play in Cleaning and Disinfecting Practices?

What can leadership do to make

disinfection a priority and easily

accessible to staff?

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Examples of SurfacesThat Are Frequently Touched

• Door handles• Call button• Telephone• Bed rail• Tray table• Bedside table• Light switches• Bedside commode

Let’s Chat!

Challenges and Solutions to Ensuring aClean and Disinfected Environment

• What cleaning and disinfecting challenges do you experience in your facility?

• What solutions do you propose to address these challenges in your facility?

• How can you support a culture of safety around cleaning and disinfection?

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Get Prepared to Engage LTC Staffin Skills Practice

Obtain the cleaning products and read the instructions on the labels.• What PPE needs to be worn?

• What’s the contact time?

• How do you properly store the cleaning product?

• How do you properly dispose of the cleaning product?

Engagement Activity:How Clean Is it Really?

Fluorescent marker: if present after cleaning, indicates need to repeat Adenosine triphosphate (ATP): measures level ofsoil on a surface

Environmental cultures: surface sampling for bacteria

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Wrap-Up

• Clean environment and clean equipment keep residents safe. Things that may look clean can still have germs on them.

• Know how to safely and properly use disinfectants utilized at your facility.

READ THE LABEL!

• Clean and disinfect surfaces that are touched a lot and any time you see a surface that is soiled with body fluids.

• Follow routine catheter care and maintenance to prevent catheters from becoming an entry portal for bacteria.

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Take the Pledge…

Stay Updated with Useful Resources

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1. AHRQ Safety Program for Long-term Care: HAIs/CAUTI websiteLogin information

Username: ltcsafetyPassword: ltcsafety

2. TeamSTEPPS® for Long-term Care

Stay Updated with Useful Resources

3. CatheterOut.org

4. Take the Pledge… to Practice All Infection Prevention Skills

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ReferencesApplegate, D. Simpson, K. Wesley, C. Carling, P. (2012). Evaluation of environmental cleaning in Long Term Care Facilities. IDSA ID Week 2012,

Poster No. 1605. Retrieved from https://idsa.confex.com/idsa/2012/webprogram/Paper35775.html

Fowler K. Catheterout. Retrieved from http://catheterout.org

State Operations Manual. Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Centers for Medicare and Medicaid Services (CMS). (2015, July 10). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_a_hospitals.pdf

Duckro, A.N. Blom, D.W. Lyle, E.A. Weinstein, R.A. Hayden, M.K. (2005). Transfer of vancomycin-resistant enterococci via health care worker hands. Archives of Internal Medicine 165, 302-307.

Kramer, A. Schwebke, I. Kampf, G. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Diseases. 6(130), retrieved from http://www.biomedcentral.com/content/pdf/1471-2334-6-130.pdf.

McFarland, L.V. Beneda, H.W. Clarridge, J.E. Raugi, G.J. (2007). Implications of the changing face of Clostridium difficile disease for health care practitioners. American Journal of Infection Control. 35(4), 237-253.

Maki, D.G. Tambyah, P.A. (2001). Engineering out the risk of infection with urinary catheters. Emerging Infectious Diseases. 7(2), 342-347. Retrieved from http://www.cdc.gov/ncidod/eid/vol7no2/makiG1.htm

Mody, L. Bradley, S.F. Galecki, A. Olmsted, R.N., Fitzgerald, J.T. Kauffman, C.A. Saint, S. Krein, S.L. (2011). Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices. Clinical Infectious Diseases. 52(5), 654-651.

Murphy, C.R. Eells, S.J. Quan, V. Kim, D. Peterson, E. Miller, L.G. Huang, S.S. (2012) Methicillin-resistant Staphylococcus aureus burden in nursing homes associated with environmental contamination of common areas. Journal of American Geriatric Society. 60(6), 1012-1018.

Siedlaczek, G. Infection Prevention & Control Services. [Powerpoint slide]. Retrieved from http://www.stjoeschelsea.org/documents/meded/InfectionPrevent.pdf

Zimmerman, S. Gruber-Baldini, A.L. Hebel, J.R. Sloane, P.D. Magaziner, J. (2002). Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors. Journal of American Geriatric Society. 50(12), 1987-1995.