Infection control practitioners (ICPs) in long-term care facilities (LTCFs) are usually nurses who have a great need for information, education, and networking. These practitioners are struggling to develop and refine their programs; and while many of their concerns are similar to those of hospital ICPs, other concerns seem unique to LTCFs. These concerns seem to be reflected in the concept of "caring" and its clash with the necessities of asepsis and general infection control. Persons who reside in LTCFs are, in reality, making these facilities their homes. A balance is needed among the physiologic, psychologic, and sociologie aspects of caring. The multiple roles and time constraints of LTCF ICPs are problematic, and contribute to the uncertainty felt regarding the adequacy of their infection control programs.
The Association for Practitioners in Infection Control (APIC) has been helping its hospital members since 1972. In recent years, it also has been reaching out to LTCF practitioners as well. APIC has long recognized that all the elements leading to nosocomial (institutionally-associated) infections are present in LTCFs and that almost as many infections occur in LTCFs as in hospitals. The nationwide hospital Study on the Efficacy of Nosocomial Infection Control (SENIC) documented the effectiveness of hospital programs in regard to standard surveillance and control measures (Haley, 1985).
A SENIC-type project is currently under way using questionnaires in the state of Maryland; as yet, there are no published controlled studies that analyze the efficacy of specific infection control measures in the LTCF setting (Pritchard, 1992). A Canadian consensus conference in 1989 led to proposed surveillance criteria and definitions of nosocomial infections. The proposed criteria are more in keeping with the LTCF environment (McGeer, 1991); they need to be used by more ICPs in LTCFs and studied for efficacy prior to making any firm recommendations for their universal adoption.
Risk assessment for LTCF infection control purposes is another area that differs significantly from hospitals. In a study conducted by Kunin and associates (1992), the ability of a resident to perform his or her own activities of daily living, the presence of urinary catheters, age, cancer, cardiac disease, diabetes, and poor skin condition were found to have a significant independent association with mortality. There are no standard guidelines for LTCF risk assessment and there are differences in the various types of LTCFs. Both the risk factors for infection specific to the resident population and the nature of the faculty must dictate the scope and focus of the infection control program.
To assist the LTCF practitioner, APIC has published a helpful document APIC Guidelines for Infection Prevention and Control in the Long-Term Care Facility (Smith, 1992). This Guideline defines the elements of a generic infection control program and is based on current studies and experiences in the LTCF setting. The Guideline focuses on those LTCFs known as nursing homes, which care for the elderly or chronically ill, but they generally can apply to special LTCF situations, such as institutions for the mentally retarded, psychiatric hospitals, and rehabilitation hospitals. The Guideline offers a detailed description of potential reservoirs of infection and transmission factors, and gives an overview of the magnitude of the nosocomial infection problem in LTCFs. All of the elements of a good general infection control program are outlined in the Guideline. Sufficient explanation of the importance of each element is included, but each facility must interpret the elements according to the unique needs of their own group of residents. Additional interpretive assistance can be obtained from various other sources, including Infection Control in Long-Term Care Facilities (Smith, 1984), which is currently being updated.
According to the Guideline, an LTCF infection control program should include the following elements:
* Surveillance based on systematic data collection to identify nosocomial infections in residents;
* A system for detection, investigation and control of institutional outbreaks of infectious diseases;
* An isolation/precautions system to reduce risk of transmission of infectious agents;
* Infection control policies and procedures;
* In-service education for infection prevention and control;
* A resident health program;
* An employee health program;
* A system for antibiotic review and control;
* Product review/evaluation;
* Disease reporting to public health authorities; and
* Compliance with federal, state, and local regulations.
The Guideline also offers points that should be considered for outbreak control, surveillance, isolation/universal precautions practices, and the functioning of the infection control committee. The environmental construction and sanitation aspects of the facility - with a focus on asepsis and handwashing - also are discussed, and resident care practices of most concern to infection control programs are mentioned. Resident and employee health programs are outlined, with a focus on screenings and vaccinations for disease prevention. Education, antibiotic review, and other miscellaneous aspects of a wellconstructed infection control program are included.
Additionally, the Guideline outlines the general duties and educational needs of the ICP:
* An individual familiar with LTCF resident care problems - the ICP - should be assigned the responsibility of directing infection control activities in the LTCF;
* The ICP is responsible for implementing, monitoring, and evaluating the infection control program for the LTCF;
* The ICP should be guaranteed sufficient time to carry out the directives of the Infection Control Committee;
* The ICP should have written authority to institute infection control measures (such as isolation or visitor restrictions) in emergency situations;
* The ICP should be knowledgeable of the federal, state, and local regulations dealing with infection control in the LTCF;
* The ICP should communicate with other relevant facility committees;
* 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; and
* The ICP should have sufficient infection control knowledge 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.
Research and Educational Needs
As LTCFs continue to accept more complex-care residents, the need to refine their infection control programs becomes apparent. LTCFs should continue to be the subject of many research projects. In regard to researchable practice issues, the nation's LTCFs are in about the same situation as were US hospitals 20 years ago. There is much to be learned and much to be improved upon. Based on the outlined duties and educational needs in the Guideline, it becomes obvious that many LTCF ICPs are not receiving adequate training, facility support, or time to accomplish program goals.
The value of retaining an adequately trained ICP should be as evident to the administration of the LTCF as it is to the administration of the hospital. Each year APIC offers an excellent basic training course for new practitioners that includes a special breakout session for those from LTCFs. This course replaces the old Centers for Disease Control training for new ICPs. APIC's Annual Educational Conference and International Meeting hosts a pre-conference with a day-long training session for LTCF practitioners. The annual conference itself encompasses many issues of interest to LTCFs.
Discussion is currently under way at APIC to consider 2-day regional long-term care conferences throughout the country, which could make attendance easier. APlC has an active LTCF committee that plans these activities. One function of the committee includes the quarterly publication of the Infection Control in Long-Term Care Facilities Newsletter. APIC recently further displayed its commitment to helping LTCF practitioners when it sanctioned the first "all LTCF-member" chapter. All other chapters throughout the nation were originally composed of hospital ICPs with LTCF members usually in the minority. This minority status is rapidly changing, and APIC membership now can be invaluable to the LTCF practitioner.
Along with the new Guideline for infection control comes the first step toward developing universal program requirements for LTCFs, even though the broad Guideline topics are open to interpretation and research. ICPs from all LTCFs should enlist the support of their administrators in order to put the elements of the Guideline into place in thenown infection control programs.
- Haley, R. W., Culver, D.H., White, I.W., Morgan, W.M., Emori, T.G. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am } Epidemiol 1985; 121:182205.
- Kunin, CM., Douthitt, S., Dancing, J., Anderson, J., Moeschberger, M. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol 1992; 135:291-301.
- McGeer, A., Campbell, B., Emori, T.G., Hierholzer, WJ., Jackson, M-, Nicolle, L.E., et al. Definitions of infection for surveillance in long-term care facilities. Am / Infect Control 1991; 19:1-7.
- Pritchard, V. SENIC project for long-term care. Infection Control in Long-Term Care Facilities Newsletter 1992; 3:1.
- Smith, EW. Infection Control in long-term care facilities, 1st ed. New York: John Witeyand Sons, 1984.
- Smith, P.W., Rusnak, P.G. APIC guideline for infection prevention and control in the longterm care facility. Mundelein, IL: Association for Practitioners in Infection Control, 1992.