1. Mary Beth White-Comstock, RN CIC
Sticking it to them: Infection-control practices in Virginia assisted living facilities
Ami S. Patel, PhD MPH
Joseph Perz, DrPH MPA
Mary Beth White-Comstock, RN CIC
C. Diane Woolard, PhD MPH
Good afternoon. This afternoon I will be discussing an epidemiological survey that was conducted to assess infection-control practices in Virginia assisted living facilities. The survey was conducted in response to two hepatitis B outbreaks where inadequate infection control practices were identified as the source. To begin, I would like to provide you with a background on assisted living.

2. Assisted Living Facilities (ALFs)
Different from nursing homes
Facilities for persons needing assistance with activities of daily living
Offer intermediate level of long term care for adults
Operate under a social model
Assisted living facilities or ALFs are different from nursing homes. These facilities care for people needing assistance with activities of daily living. Residents must be ambulatory and not require skilled nursing care. ALFs offer an intermediate level of long term care for adults. Assisted living facilities operate under a social model. In contrast, nursing homes operate under a medical model.

3. Increase in ALFs 613,000 beds in 1991 938,000 beds in 2004
With the aging US population more persons are residing in assisted living facilities. In 1991, there were an estimated 613,000 beds compared to close to one million in As shown on this figure from the National Center for Assisted Living, the number of beds is projected to double by With this increase, the medical needs of ALF residents is also expected to become more demanding.

4. Governance over ALFs No federal oversight Regulations vary by state
Virginia
Licensed by the Department of Social Services (DSS)
State regulations did not mention specific infection control requirements
OSHA bloodborne pathogen standard
ALFs are currently not subject to any federal oversight unlike nursing homes. Licensing regulations for assisted living vary by state with some state agencies regulating both nursing homes and ALFs. In Virginia, ALFs are licensed by the Department of Social Services or DSS. At the time of this survey, there was no state regulation which specifically addressed elements of infection control such as the OSHA bloodborne pathogen standard.

5. Hepatitis B Outbreaks in Assisted Living Facilities — August 2005
Virginia Department of Health (VDH) notified
Outbreak 1
Assisted living facility with 84 residents
Two cases of acute hepatitis B (HBV)
Adjacent rooms
Diabetic
Outbreak 2
One acute hepatitis B death
In August of 2005, the Virginia Department of Health or VDH, was notified of suspected hepatitis B outbreaks within two Richmond City assisted living facilities.
VDH was notified of the first outbreak on August 2, This outbreak took place in an assisted living facility with 84 residents. The two case-patients with acute hepatitis B or HBV lived in adjacent rooms and were both diabetic.
On August 14, 2005 VDH was alerted of another potential outbreak of hepatitis B in Richmond City. A resident of a local assisted living facility died from complications of acute hepatitis B.

6. Outbreak Investigation Results
Outbreak 1 serologic testing results
7/39 persons = 18% positive
7/20 diabetics = 35% positive
Outbreak 2 serologic testing results
4/29 persons tested = 14% positive
All cases among diabetic residents who had blood glucose monitored by facility staff
Subsequently, the state and local health departments investigated these two potential outbreaks.
In outbreak 1, 7 of the 39 at-risk persons tested, including the 2 original symptomatic cases, were classified as having acute HBV infection. Among diabetics tested, 35% were positive.
In outbreak 2, 4 of the 29 at-risk persons, including the deceased index patient, were classified as having acute HBV infection.
All of the residents with acute HBV infection were diabetics who had glucose monitoring performed by assisted living facility staff.

7. Infection Control Assessments
Glucose monitoring equipment shared among diabetic residents and staff
Glucometers and penlet fingerstick devices were not cleaned between uses
No infection-control policies
There were several interesting observations made from the infection control assessments at these two outbreak facilities.
Glucose monitoring equipment was shared among residents and diabetic staff, not assigned to individuals as recommended
Glucometers and penlet fingerstick devices, where the lancet was changed but the housing or penlet was reused, were not cleaned between uses and had dried blood visible on their surfaces.
Lastly, the assisted living facilities did not have any infection control policies in place.

8. Outbreak Response Outbreak facilities educated
Collaboration with Virginia Department of Social Services and CDC
Educational mailing to all 640 Virginia assisted living facilities
Follow-up survey
In response to the outbreaks, the involved ALFs were educated regarding existing recommended practices. VDH collaborated with DSS and CDC in preparing an educational mailing distributed to all 640 Virginia assisted living facilities in September 2005
In addition, the CDC and VDH worked together to plan a follow-up survey.

9. Survey Objectives
Characterize existing glucose monitoring and infection control practices
Promote safe procedures
OSHA bloodborne pathogen standard compliance
Identify educational and policy needs
The objectives of this follow-up survey were to characterize existing practices and promote safe procedures including assisting with OSHA bloodborne pathogen standard compliance. Lastly, the results of the survey would be used to identify educational and policy needs.

10. Survey Sample 155 ALFs in central Virginia Random sample
Sampled ALFs were contacted by mail and telephone
Target sample size = 50 ALFs
The sampling frame for the survey consisted of 155 ALFs within central Virginia. We drew a random sample of ALFs within this licensing area and contacted these ALFs by mail and telephone. We sought to achieve a sample size of 50 ALFs.

11. ALF Site Visits Conducted April – November 2006 Questionnaire
Resident and staff characteristics
Diabetes management practices
Infection control practices
Observational/walk-through survey
Educational discussion
From April to November 2006, data collection interviews were conducted. The questionnaire used in on-site interviews with facility administrators and/or nursing supervisors collected information on resident and staff characteristics, diabetes management, and infection control practices. In addition to the questionnaire, an observational or walk-through survey was conducted. The interview concluded with a brief educational discussion.

12. Location of Surveyed ALFs in Virginia
50 ALFs surveyed
We surveyed 50 ALFs in 16 counties or cities, highlighted here in pink, within central Virginia. Richmond City, the site of the 2 outbreaks, is highlighted in yellow.

13. Facility Characteristics
Ownership
32% Individual
68% Corporation
12% affiliated with nursing home
Median number residents = 41 (3–111)
Median percentage of diabetics = 14 (0–50)
With respect to facility characteristics, 32% of ALFs were individually owned. 68% were owned by a corporation, limited liability corporation, partnership, or unincorporated association and for analysis were classified as having corporate ownership. 12% of ALFs were affiliated with a skilled-nursing facility on-site.
The median number of residents in all of the ALFs surveyed was 41 with a range of 3 to 111 residents. The median % of diabetics at the time of interview was 14%.

14. Median Number of Full-Time Health-Care Staff by ALF Size
< 17 beds
n = 10
17-50 beds
n = 15
>50 beds
n = 25
Total
n = 50
Licensed nurses 2 1
Certified Nursing Assistants 9
Medication Technicians 4 8 5
This table shows the median number of full-time healthcare staff by three ALF size groups. These groups were established by dividing the sample licensing capacity distribution into thirds. The median number of full-time direct care staff for all ALFs, shown in the last column, was 1 licensed nurse, 2 certified nursing assistants, and 5 medication technicians per facility.
The greater than 50 beds group, was the only group which had a median number of licensed nurses greater than 0.

15. Shared Devices 7/45 (16%) shared penlet fingerstick devices
0/7 (0%) cleaned between residents
8/50 (16%) shared glucometers
4/8 (50%) cleaned between residents
Sharing practices did not differ by facility
Size
Ownership
Penlet fingerstick devices were shared within 16% of ALFs who used such devices; none of these seven facilities cleaned the device between residents. 16% of ALFs shared glucometers and half of those facilities cleaned glucometers in between residents. Sharing practices did not differ by facility size or ownership

16. Safety Equipment 31/50 (62%) did not use safety lancets
11/49 (78%) did not use safety needles
Use of safety devices (lancets or needles)
Did not differ by ownership (Fisher’s Exact P = .70)
Larger ALFs more likely to use safety devices (Fisher’s Exact X2 d.f. 2, P = .01)
62% of ALFs surveyed did not use safety lancets. These lancets, pictured on this slide, are specifically designed to be used once and then disposed.
78% did not use safety needles to administer injectable medications. Like safety lancets, these needles retract.
The use of these safety devices did not differ by ALF ownership. However, larger ALFs were significantly more likely to use safety devices as compared to small and medium sized ALFs.

17. Bloodborne Pathogen Standard Compliance by ALF Size
< 17 beds
n = 10
17-50 beds
n = 15
>50 beds
n = 25
Bloodborne Pathogen Standard Compliance
4 (40%)
6 (40%)
23 (92%)
No Bloodborne Pathogen Plan
6 (60%)
9 (60%)
2 (8%)
Compliance with the bloodborne pathogen standard was defined as providing the hepatitis B vaccine to employees, using a regulated sharps container with appropriate disposal means, and having a policy regarding blood spill clean up and post-exposure follow-up after a sharps injury. Using chi-square analysis, we determined that compliance was significantly higher among larger ALFs.
Fisher’s Exact X2 d.f. 2, P -value = <.001

18. Bloodborne Pathogen Standard by ALF Ownership
Individual
n = 15
Corporation
n = 35
Bloodborne Pathogen Standard Compliance
6 (40%)
27 (76%)
No Bloodborne Pathogen Plan
9 (60%)
8 (24%)
Using the same definitions, we assessed bloodborne pathogen standard compliance by ALF ownership. ALFs owned by individuals less frequently had a bloodborne pathogen plan compared to ALFs owned by or affiliated with a corporation or association.
X2 d.f. 1, P -value = <.001

19. Walk Through Observations
Yes
n (%) No
% (n)
Regulated sharps container
45 (90%)
5 (10%)
Handwashing supplies at sink
42 (89%)
5 (11%)
Sink near glucose monitoring areas
33 (67%)
16 (33%)
Results of the walk-through survey identified that 10% of ALFs did not use a regulated sharps container.
11% of ALFs did not have handwashing supplies such as soap and paper towels at sinks used by staff.
Lastly, 33% of ALFs did not have a sink close to their glucose monitoring areas – this may impede staff from washing their hands after performing direct care procedures.

20. Conclusions
Corporate-owned ALFs were more likely to have infection-control plans
Despite outreach
Greater than one-third noncompliant with federal recommendations
Glucose monitoring device sharing persisted
Educational need still exists
In conclusion, the results of this survey found that ALFs affiliated with corporations are more likely to have infection control plans that comply with the OSHA bloodborne pathogen standard. Despite outreach by the health department and longstanding recommendations, over one-third of ALFs were noncompliant or not aware of the OSHA bloodborne pathogen standard or CDC recommendations. Sharing practices for blood glucose monitoring devices continues to occur and did not differ by ALF size or ownership. Lastly, it was evident that an educational need for infection control training still exists.

21. Limitations Unable to fully observe practices
Sample limited to central Virginia
ALF licensing regulations vary by state
The major limitations of this survey were that we were unable to fully observe staff practices during our interview; thus we relied on self-report in many instances. Our sample was limited to central Virginia and may not be representative of other areas of the state. Finally, ALF licensing regulations vary by state – our findings and recommendations may not be applicable to other states.

22. Recommendations Educate ALF staff
Promote bloodborne pathogen standard compliance in assisted living
Incorporate specific guidelines into state regulation
The results of this study led us to make the following recommendations. Firstly, assisted living facility staff need to be educated via in-person meetings and training workshops. Secondly, the bloodborne pathogen standard should be promoted in assisted living via fact sheets and training. Lastly, we recommend that specific infection control guidelines be incorporated into state regulations.

23. Future Actions/Activities
Infection control plans in ALFs now mandated by state regulation
Develop educational materials
Develop train the trainer program
Using epi methods to design and carry out an infection control survey provided data that drove supported efforts to incorporate infection control policies into state regulation. Virginia assisted living facilities are now required to have an infection control plan in place. Additionally, efforts are underway to develop infection control educational materials specific to ALFS as well as a train the trainer program in partnership with DSS.

24. Acknowledgments Virginia Department of Health
Mary Beth White-Comstock*
Diane Woolard *
Virginia Department of Social Services
Deborah Lloyd
CDC, Division of Viral Hepatitis
Joe Perz *
Ryan Novak
Ian Williams
CDC, OWCD, CDD, EIS Field Assignments Branch
Diana Bensyl
Disclaimer
The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.
I would like to acknowledge the following persons from the Virginia Department of Health, Virginia Department of Social Services, and the CDC especially my co-authors, Dr. Joe Perz, Mary Beth White-Comstock, and Diane Woolard. Thank you.
*Authors

26. BACK UP SLIDES

27. Characteristics of Facilities Sharing Penlets
7 Facilities shared penlet devices
71% affiliated with corporation
Facility size 16 – 94 beds
Penlets shared among 2 – 24 diabetics
None used safety lancets

28. Bloodborne Pathogen Standard Compliance
65% ALFs offered employees hepatitis B virus vaccine
Post-vaccination testing not performed
Post-exposure follow-up after sharps injury
84% follow-up
10% did not have a regulated sharps container
32 or 65% of ALFs were aware of the OSHA requirement to provide hepatitis B vaccine to their employees and subsequently offer it. None of the ALFs performed any post-vaccination testing.
84% of ALFs performed some form of post-exposure follow-up after an employee’s sharps injury.
10% of ALFs did not have a regulated sharps container. Makeshift sharps containers, typically at smaller ALFs, included a bleach bottle or tupperware container. The majority of facilities which had a regulated sharps container had contracts with private companies of pharmacies to dispose of the waste.