An Educational Resource for Long-Term Care

​​​​​Welcome to the spring edition of The Lowdown. Spring is a time of warmer temperatures, more daylight, and in- creased activity. Spring is also the time we recognize World Hand Hygiene Day and Hepatitis Awareness Month. It is also a good time to review and improve practices that may seem routine but are important. Happy reading!

The World Health Organization (WHO) celebrates May 5 as World Hand Hygiene Day through its SAVE LIVES: Clean Your Hands campaign, which focuses on the im- portance of hand hygiene in healthcare. The objectives of World Hand Hygiene Day are to promote optimal hand hygiene practices and glove use and to alert others to the environmental impact of waste generating from disposable gloves.¹

Hand hygiene is the most important measure you can use to prevent the spread of infection! Studies consistently show that improved hand hygiene reduces infection rates. When the culture of a healthcare facility values and practices hand hygiene, residents, staff, and visitors feel protected. As healthcare workers, it is important to be a good role model by practicing proper hand hygiene and reinforcing its im-portance with everyone: staff, physicians, residents, family members, and visitors.²

WHO has defined five key moments for hand hygiene.³

Approximately 11% to 59% of long-term care residents are colonized with gram-negative, multidrug-resistant bacteria. Some of the identified colonization risk factors include advanced age, male gender, chronic diseases such as diabetes and cancer, recurrent hospitalization, increased interaction with healthcare workers, antibiotic use, advanced dementia, fecal incontinence, and residing in a long-term care facility.4 Gram-negative, drug-resistant bacteria cause serious infections, including pneumonia, wound infections, meningitis, and bloodstream infections. Long-term care residents are at risk of infection due to a weakened immune system from advanced age and multiple comorbidities. To prevent the transmission of these organisms, it is important to have a strong infection prevention program. Identifying residents at increased risk of colonization will help infection prevention designees to direct their resources to prevent transmission.5

Consistently following basic infection prevention practices is key to preventing spread of multidrug-resistant organisms (MDROs). Effective hand hygiene is necessary and is required before and after direct patient contact; after contact with body fluids, mucous membranes, or non-intact skin; after contact with the resident’s environment; and before donning and immediately after removing gloves. Environmental cleaning is important to prevent the transmission of bacteria. Shared equipment should be cleaned and disinfected between residents.4

Use Enhanced Barrier Precautions (EBP) for residents col- onized with an MDRO or who have an indwelling medical device or wound. Wounds and indwelling devices (e.g., cen- tral line, urinary catheter, feeding tube, tracheostomy/ven- tilator) are risk factors for carrying or acquiring MDROs.⁶

EBP requires the use of personal protective equipment (PPE) for high-contact resident care activities that have been found to result in transfer of MDROs to the hands and clothing of staff. EBP provides guidance for PPE use and room restriction in nursing homes for preventing trans- mission of MDROs. EBP requires gowns and gloves for certain residents during specific care activities but is not as restrictive as Contact Precautions, as the resident is not restricted to their room and PPE is not required for every entry into the room.⁵

Gowns and gloves would not be required for resident care activities other than those listed above unless needed to follow standard precautions. Residents in EBP are not restricted to their rooms or stopped from participation in group activities.

​Contact Precautions are required for:⁷

Gowns and gloves must be worn when entering ANY con- tact precaution room and if the resident is restricted to their room (except for medically necessary care).⁶

When implementing any type of Transmission-Based Pre- cautions or EBP, educate and reinforce facility expectations for hand hygiene, PPE use, environmental cleaning, and cleaning and disinfecting medical equipment/devices.^5,6

Scabies is a highly contagious, parasitic skin infestation caused by a microscopic mite: Sarcoptes scabiei. Scabies is mainly spread by direct skin-to-skin con- tact during patient care or, in severe cases, the mites can transfer from infested clothing, bedding, or the environment. Topical lotions or medications can serve as a reservoir for mites that can survive up to seven days in oil-based solutions.⁸

The mites cannot jump or fly, but they can crawl. A fertilized female mite tun- nels under the surface layer of the skin and repeatedly deposits two to three eggs a day. These eggs hatch in three to four days then surface, burrow, and feed on skin cells until they mature. After which, the cycle repeats. Scratching the itchy skin can result in mites under the fingernails, which then can be spread to other parts of the body, a new host, or fomites (e.g., bedding). Transmission can con- tinue until the mites and eggs are killed.⁴

The primary symptoms are a raised rash and intense itching caused by an al- lergic reaction to the mites, eggs, and fecal pellets deposited under the skin in the burrow. Scabies can be diagnosed by the clinical manifestation; an ink test to identify a burrow; the microscopic examination of skin scrapings for mites, their eggs, or fecal matter; or by an adhesive tape test to visualize mites.4

Early diagnosis and treatment are important to prevent an outbreak. Prescription scabicides are used to kill scabies mites and their eggs. Persistent itching may be present for several weeks after treatment as the dead mites, eggs, eggshells, and fecal pellets emerge from the burrows. Repeat treatment may be necessary.⁴

Place residents in Contact Precautions with strict use of PPE until 24 hours after treatment was started. Launder linens in hot water and dry on high heat. Clean and vacuum the room daily and change the vacuum bag daily. Secure items that can’t be laundered in a plastic bag for

at least 72 hours. Educate staff, residents, and visitors on symptoms and control methods.4 Additional information and tools are available from the Patient Safety Authority

May marks Hepatitis Awareness Month and Hepatitis Test- ing Day (May 19). It is important to make people aware of hepatitis infection and remind them that hepatitis A and hepatitis B can be prevented, and hepatitis C can be cured.⁹

Hepatitis is an inflammation of the liver: a vital organ that processes nutrients, filters the blood, and fights infections. When the liver is inflamed or damaged, its function can be affected. Heavy alcohol use, toxins, some medications, and certain medical conditions can cause hepatitis. However, hepatitis is most often caused by a virus. Millions of Amer- icans are affected by viral hepatitis, with the most common types in the United States being hepatitis A, hepatitis B, and hepatitis C.^10,11

Many people with hepatitis do not have symptoms and do not know they are infected. If symptoms occur with an acute infection, they may appear anytime from two weeks to six months after exposure, while symptoms of chronic viral hepatitis may take decades to develop. Symptoms of hepatitis include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, gray-colored stools, joint pain, and jaundice.^8,9

Hepatitis A is spread when a person ingests fecal mat- ter—even in microscopic amounts—from objects, food, or drinks contaminated by feces or stool from an infected person. Treatment consists of supportive care. There is an effective vaccine available to prevent hepatitis A.^8,9

Hepatitis B is primarily spread when blood, semen, or cer- tain other body fluids from a person infected with the hep- atitis B virus enter the body of someone who is not infected (even in microscopic amounts).⁸

Hepatitis B is a leading cause of liver cancer, and about 2 in 3 people with hepatitis B do not know they are infect- ed. Fortunately, an effective vaccine is available. Treatment includes supportive care, monitoring for signs of progres- sion, and antiviral drugs.8

Hepatitis C is spread when blood from a person infected with the hepatitis C virus enters the body of someone who is uninfected (even in microscopic amounts).⁸

Hepatitis C infection is a leading cause of liver cancer and liver transplants. About 50% of people with the hepatitis C virus do not know they are infected, and 3 in 4 people with hepatitis C were born between 1945 and 1965. There is no vaccine available for hepatitis C, but there are medications available that can cure hepatitis C infection.8,9

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