Infection Control practices in Long term care

[Nascar nurse, ASN, RN]

Now that I am more involved with the admission process than ever.. I have noted that we seem to have a very high rate of residents coming to use with VRE and MRSA. Seems our local hospital is doing nares cultures and rectal cultures as a standard procedure w/ treatment for everyone. This is presenting a real challenge with bed availability as we just don't have enough private rooms (in our facility and in the surrounding LTC's either). I'm also not completely sure we are up to standard on our current infection control procedures. So, some questions for all of you.. PLEASE RELATE TO LONG TERM CARE practice only as I know the hospital does things much differently.

1. Are you all still routinely giving private rooms to multi-drug resist residents, cohorting residents, or are you even diligently paying attention to this?

2. Do you follow contact precautions, ie: signs on doors, bins in room, mask/gown as needed? I personally think this is over the top sometimes, (I have always been one to preach garbage is garbage..dirty laundry is dirty laundry), BUT on the other hand I see far to many CNA's leaving rooms with arms loaded with dirty linen/not bagged and hugged next to their uniform. Maybe if we had the bins, etc at least they wouldn't carry the yucky stuff all thru the hall on the shirts?

3. Are your local hospitals routinely screening everyone they send? Doing anything different because of it.

Thanks, I know wediscussed this in part recently, but I couldn't find it when I searched.

[CapeCodMermaid, RN]

Our hospital was swabbing every orifice for a while, too. They seem to have backed off. Unless the resident has MRSA or VRE in their sputum, we don't insist on a private room. We do, however, for active CDiff since that is very easily transmitted. If they have a huge wound with MRSA, we keep a bin in their room for the linen so the staff is carrying a bag through the hall, not the linen. My problem seems to be the opposite of yours: we had a woman with MRSA in a wound. The wound was tiny..about .5cm in diameter and all the drainage was contained in the dressing. I saw a CNA come going into the room with gloves, a mask,a gown,and goggles! It's not easy to find specific info on infection control precautions in LTC since it is so different from the hospital. I found my lab people to be very helpful sharing the latest from the CDC and DPH.

[Nascar nurse, ASN, RN]

My problem seems to be the opposite of yours: we had a woman with MRSA in a wound. The wound was tiny..about .5cm in diameter and all the drainage was contained in the dressing. I saw a CNA come going into the room with gloves, a mask,a gown,and goggles!

Well I have seen this as well and I think we need to avoid this extreme too. I have seen the same situation as you describe and along with all of the PPE, some staff thinking that even the food tray should be totally disposable.. oh come on people the MRSA bug is not going to jump off the foot wound/out of the dressing/run the marathon up the body to sneak a bite of the food. . (Before anyone even jumps in.. yes I am completely aware that some residents will "dig" at the area and this causes the infection to get where it doesn't belong, but that is not the situation I am trying to describe).

I have been looking on the CDC site, and you're right, I just can't find any black and white "rules".

[SuesquatchRN, BSN, RN]

There's one thing I want to mention that has always been annoying to me.

Because it's a home there are no hand sanitizer dispensers at easily usable intervals, or upon entry and exit.

Well, that's marvelous, but our NH recently had a GI bug gallop through it, 50+ out of 80 residents got it.

Find a way to put up sanitizer dispensers! I had to be on and off the unit frequently during this epidemic and had no way to easily clean my hands. That strikes me as a silly paeon to "it's a home," while meanwhile I've seen the same silliness with full PPE for MRSA in the nares.

[CapeCodMermaid, RN]

While we are lucky at my facility to have hand sanitizer readily available every few feet in the hallways, the last place I worked did not. We did,however, have large containers on each med cart and the staff each had a small bottle in their pocket.

[achot chavi]

We keep hand sanitizers on all med and tx carts and outside of rooms that have pts with MRSA or Cdif or VRE or whatever. Important detail. Some aides go overboard at first then calm down. We had to convince them all to be careful with their uniforms- not to bring home any "pets" and not to travel home on the bus wearing the (dirty) uniform.

We had our Medical Director give an inservice explaining how these things spread, what to be careful for and what is overboard. That helped to a certain point. We have to instruct family members who go "underboard" that if they refuse to wash hands after the visit, they are not to approach other patients, a common occurrence as long term pts have become friends with each other and their families as well. I think asking the families to wash their hands is a minimum request and they take it so hard. It is hard for them to beleive that their father is "infected".

[CoffeeRTC, BSN, RN]

We do not isolate for those either. Even with the sputum. (If they are coughing I really think we should...what is the rule on that one?)

No special bins either.

Hand sanitzer in little bottles for everyone to carry.

Sign on the door to check with the nurse..that way we can do some teaching with visitors.

We've been fortuanate not to have a big problem.

[achot chavi]

I guess our families are illiterate or dont know how to identify a nurse ( we all wear white) cause we've got those signs up too and they keep ignoring them- LOL

I've tried to careplan noncompliance from the families and keep failing. I report to the SW and leave it at that.

Yes I think resp- tract infections with MRSA or the like should be isolated- I wouldn't risk the lawsuit!!!!

[Nascar nurse, ASN, RN]

With resp MRSA.. I was always taught that there is some magical "3 foot" rule. As a healthcare provider, if your just walking into the room and not within a 3 foot range, really no need to go thru all the gown/mask, etc, especially if the resident isn't actively coughing and hacking all over the place. Of course I can't say that I recall ever seeing this "3 foot" rule in writing, so I am throwing it our there for discussion. Have you all heard of this?

In general, it doesn't sound like any of us have a real clear cut way of doing things. Kind of scary because when is this all going to blow up into something big someday.. but then again... I hate going overboard too.

Thanks for the replies

[Havin' A Party!, ASN, RN]

Hey, folks. Like most of us here, I've gotta bone up on this area as well.

Do recall that C-Diff requires water / soap precautions (not portable dispenser cleaning) to ensure that those buggies are done for.

Intend to do additional research on IC.

Thanks for bringing all this up, NN.

[LeeAnna328]

C.Diff patients are only standard precautions, unless coming into contact with their feces, if their symptoms are "controlled". If they are not controlled, then they are on contact precautions. The soap/water thing does apply, since C.Diff is a spore-forming bug, and hand sanitizer doesn't kill the spores (which can survive on an inanimate object for up to 6 months!) At my facility, we do not insist on a private room for C.Diff, but we do try and cohabitate the C. Diff people. Also, if we have a C.Diff positive patient in a room with a non-infected patient, we make sure that they don't share the toilet. What I mean is that if the C. Diff patient in incontinent and their room mate uses the toilet, there shouldn't be a cross-contamination problem.

With MRSA, we use contact precautions when coming into contact with the colonized area (with the bins/gowns/etc). If it's MRSA of the sputum, then it's droplet precautions within 3 feet. We have maintenance put tape on the floor to remind everyone.

Mostly, we try to be reasonable. Hand washing is still the most effective infection control prevention measure, and we do have hand sanitizer all over the place.

Hope this helps!

[CapeCodMermaid, RN]

Tape on the floor?? Seems an insulting thing to do. Surveyors in this state would NOT like it...as the DNS, neither would I.