AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Clean Equipment and Environment Promotes Safe Resident Care Training Module # 2 for All Long-term Care Staff Current as of July 2015

Learning Objectives Upon completion of this session, long-term care staff 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 catheter- associated urinary tract infection (CAUTIs) Explain the role of the environment as a place where pathogens can become a source of infection for residents and staff List the important steps when using environmental disinfectants 2

Protecting Residents Against Infection The Chain of Transmission: Six Links 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 3

Breaking the Chain of Infection: The Role of LTC Facility Staff The Chain of Transmission: 6 Links How Can You 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 precautions No unnecessary antibiotics Proper waste disposal Siedlaczek G. SJMHS 4

Indwelling Urinary Catheter: Entry Pathways for Microbes Bladder Urine Collection Bag Urethra (Urinary tract entrance) Entry during insertion Bacteria movement up the catheter Breaks in the catheter tubing or collection bag Contamination of the catheter tubing or collection bag Figure Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April CMS, State Operations Manual,

Entry Pathways for Microbes: Urine Collection Opening Sterile technique is important when inserting urinary catheters Routine hygiene is important (e.g., cleansing the area around the urethra during bathing or showering) Disinfect port with alcohol swab for 15 seconds before obtaining a urine culture Check site for possible disconnection of catheter from drainage bag System may become an open system if the outlet is left unclamped Catheterout.org 6

Indwelling Urinary Catheter: Stabilization Devices Can Help Prevent Microbe Entry 7 Catheter Stabilization Devices Seal over junction between catheter and drainage bag.

Hand Hygiene 8 Good Better Best Plain soap Antimicrobial soap Alcohol-based hand rub

Case Review of an Outbreak The case of the common urinometer A LTC facility has an outbreak of MDR-Serratia marcescens UTIs Risk factors – Use of common measuring device between residents with indwelling urinary catheters – Hands of HCWs contaminated with outbreak strain after use of device; they helped pass the microbes between residents The outbreak stopped after the measuring device was disinfected between each use Dedicate one device per resident 9 Rutala WA, et al. Am J Med 1981;70:

Role of Clean Equipment and Environment: Protecting Residents Against Infection Factors associated with increased risk of infection in residents include 1 :  Lower level of cleanliness  Higher frequency of odors  High turnover rate of nurses  Fewer certified nurses’ aides/100 beds 10 Zimmerman S, et al. JAGS 2002;50: Kramer A. BMC ID 2006; McFarland L, et al. AJIC 2007 MicroorganismSurvival on Environmental Surfaces Bacteria Clostridium difficile (C. diff.) spore> 1 yr. Methicillin-resistant Staphylococcus aureus (MRSA)7 days – 7 months Viruses Human immunodeficiency virus (HIV)3-4 days Norovirus8 hrs – 7 days

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:

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 you 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 12

Let’s Chat! Commonly Touched Areas in the LTC Facility What are some examples of commonly touched surfaces in your facility? 13 Door handles Call button Telephone Bed rail Tray table Bedside table Light switches Bedside commode

Disinfection in LTC Facilities: Read the Label First! Follow Instructions for Use – Check the label on disinfectants for the following key safety steps: Precautions you should take when applying the product, such as wearing gloves If the disinfectant is safe for the surface Whether the disinfectant needs to be diluted with water before use How to apply the disinfectant to a surface How long you need to leave it on the surface to be effective (contact time) If the surface needs to be cleaned first and rinsed after using 14

Disinfectant Wipes Keep It Wet—The surface being disinfected needs to be wet long enough to meet the contact time stated on the label. Cover the Surface Well—Choose the right size wipe based on the size of the surface. Small wipes are fine for bedside tables Larger wipes for larger areas, like mattress covers Keep the Cover Closed and Secure After Use—Keep the top of the dispenser closed to prevent the wipes from drying out. Also think about where the dispenser is stored – can residents access the wipes? 15

Let’s Chat! Improving Cleaning and Disinfection 1.Where are your cleaning and disinfection supplies? 2.What would help remind you to clean and disinfect surfaces thoroughly? 3.What is your role in ensuring surfaces are clean and disinfected? 16

Wrap-Up Clean environment and clean equipment keep residents safe. 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. 17

Take the Pledge… 18

Stay Updated with Useful Resources 1. AHRQ Safety Program for Long-Term Care: CAUTI w ebsite AHRQ Safety Program for Long-Term Care: CAUTI w ebsite Login information Username: ltcsafety Password: ltcsafety 2.TeamSTEPPS® for Long-Term CareTeamSTEPPS® for Long-Term Care 3.Take the Pledge…Take the Pledge… 19

References Applegate, D. Simpson, K. Wesley, C. Carling, P. (2012). Evaluation of environmental cleaning in Long Term Care Facilities. IDSA ID Week 2012, Poster No Retrieved from Fowler K. Catheterout. Retrieved from 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 Guidance/Guidance/Manuals/Downloads/som107ap_a_hospitals.pdfhttps:// 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, 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 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), Maki, D.G. Tambyah, P.A. (2001). Engineering out the risk of infection with urinary catheters. Emerging Infectious Diseases. 7(2), Retrieved from 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), 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), Siedlaczek, G. Infection Prevention & Control Services. [Powerpoint slide]. Retrieved from 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),