A growing body of evidence suggests the need to re-evaluate the use of personal protective equipment by health care workers during the care of nursing home residents in order to prevent multidrug-resistant organism colonization and transmission.
Colonization and infection prevention
Findings from Lona Mody, MD, MBBS, MSc, associate division chief of clinical and translational research and associate professor of internal medicine at the University of Michigan, and a team of researchers demonstrate the efficacy of a multi-modal targeted infection program (TIP) for reducing the prevalence of multidrug-resistant (MDR) organisms and incident infections among nursing home patients with urinary catheters and feeding tubes.
The TIP, which was utilized during morning and evening care activities in 418 patients, included preemptive barrier precautions, active surveillance for MDR organisms and infections, and education of nursing home staff. Results from that randomized clinical trial, published in JAMA Internal Medicine, show the program led to a decrease in new-onset MRSA infections compared with controls (rate ratio [RR] = 0.78; 95% CI, 0.64-0.96); catheter-associated urinary tract infections also were lower in the TIP group (RR = 0.54; 95% CI, 0.30-0.97). No reductions in vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions, feeding tube-associated pneumonias or skin and soft-tissue infections were observed.
In a separate study of 402 patients conducted by Mary-Claire Roghmann, MD, MS, professor of epidemiology and public health at the University of Maryland School of Medicine, and colleagues, it was demonstrated that high-contact activities of daily living — dressing and transferring residents, providing hygiene, toileting and changing linens — are significant causes of MRSA transmission from nursing home residents to workers’ gowns and gloves. In the study, approximately 28% of the patients were colonized with MRSA. The researchers found transmissions ranging from 0% to 24% with gowns and 8% to 27% with gloves, with more contamination found with gloves than gowns (24% vs. 14%; P < .01). Routine care activities like these are not ones in which health care workers would generally anticipate contact with bodily fluids, Roghmann said in an interview with Infectious Disease News.
“That’s what’s different. [Health care workers in nursing homes] wouldn’t normally be wearing gowns and gloves with routine care,” she said.
According to Nimalie D. Stone, MD, MS, of the Division of Healthcare Quality Promotion at the CDC, the studies by Mody and Roghmann complement each other.
“Both studies raise the question of, ‘Should nursing homes be thinking about the use of gowns and gloves for resident risk or resident care-based activities [in the general population] more than keying in on those residents who are colonized?’ ” Stone said.
Specific issues in nursing homes
The rising prevalence of MDR organisms among nursing home residents is occurring because of “a more medically complex population” in these facilities, according to Stone. More patients are coming directly to nursing homes from hospitals, changing the tasks health care workers typically have to perform in nursing homes.
Nimalie D. Stone
However, the nursing home is still a residential care environment, Stone said. Two issues arise in this setting with regard to infection prevention and the use of protective equipment: maintaining a home-like setting for residents and ensuring privacy.
“There’s a lot of importance [for patients and their extended families] placed on the home-like environment. There’s a lot of attention placed on maintaining residents’ privacy, because people are always walking around the building — there’s a lot of movement among residents,” Stone said. “So, if there’s signage on a door, or gowns and gloves hanging on a door, this could create an indicator that a particular resident has something going on — and there’s a privacy issue there as well as the perception of the gowns and gloves being a barrier to caregiving.”
Guidance for health care workers
According to Stone, current CDC guidelines allow for interpretation in terms of how contact precautions are applied to residents known to be colonized with an MDR organism in nursing homes.
“These are different facilities than acute-care hospitals. We want to have better practices that are evidence-based for how we use this equipment differently and to adjust to the needs of the facility that we’re working and to be sensitive to the population that’s receiving care,” she said.
The studies by Roghmann and Mody contribute to evidence about infection prevention in nursing homes and may lead to practice changes, Stone added.
“A benefit of the work Mody and Roghmann have done is that, now, those gowns and gloves might be used more broadly. They’re not specifically just for a certain bug or a certain infection, but part of the care that everyone receives,” she said.
However, Stone noted that additional work is needed before guidance can formally be changed.
“I think there are still ongoing questions that have to be addressed, including the cost implications of this kind of practice change,” she said. “I think, now, we have some research studies that have shown us different possible models for changing the use of gowns and gloves. I think there’s a little bit more that we have to learn about the acceptance and feasibility in the nursing home and for the staff before we change or update the guidance for how to do it.” – by Julia Ernst, MS
For more information:
Mody L, et al. JAMA Intern Med. 2015;doi:10.1001/jamainternmed.2015.132.
Roghmann MC, et al. Infect Control Hosp Epidemiol. 2015;doi:10.1017/ice.2015.119.
Stone ND. JAMA Intern Med. 2015;doi:10.1001/jamainternmed.2015.137.
Disclosure: The researchers report no relevant financial disclosures.