YOU’RE NOT ALONE….TOP 10 LT “ASK SPIE QUESTIONS” · 2018-10-28 · October 18, 2018 Evelyn Cook, RN, CIC YOU’RE NOT ALONE….TOP 10 LT “ASK SPIE QUESTIONS”

October 18, 2018

Evelyn Cook, RN, CIC

YOU’RE NOT ALONE….TOP 10 LTC “ASK SPICE QUESTIONS”

Moderator: Heather RidgeNurse Consultant

Evelyn Cook, RN, CICAssociate Director

Statewide Program for Infection Control and Epidemiology (SPICE)

Objectives• Discuss 10 frequently asked question themes

– Hand Hygiene

– Transmission-based Precautions

– TB Screening

– Safe Injection Practices

– Influenza Administration

– Construction Activities

• Provide evidence based rationale for responses

NO DISCLOSURES

Have you ever submitted a question to Ask-SPICE?

• Never

• 1-5 times a month

• 1-5 times a week

• 1-5 times a day

• Only when the surveyors are here

What is the preferred method for performing hand hygiene?

• We wear gloves all the time so don’t need to do hand hygiene

• Wash hands with soap and water for 1 minute

• Use an alcohol-based hand rub unless hands are visibly soiled

• Wash hands with soap and water for at least 15 seconds

OR

Hand Hygiene

• Handwashing with soap and water

• Antiseptic handwash

• Antiseptic hand rub

• Surgical antisepsis

THE ROLE OF HAND HYGIENE

THE ROLE OF HAND HYGIENE

1. Present on skin or nearby objects

2. Spread to caregiver hands

3. Endure on hands

As well as:

4. Inadequate hand antisepsis

5. Direct contact with other patients or objects

Organisms must be:

THE ROLE OF HAND HYGIENE

100-1000 colony forming units of bacteria

Hand hygiene and clean procedures

Self-Perceived Barriers to Hand Hygiene

• 35 % forgot to wash hands because they were busy

• 23% didn’t wash hands because wearing gloves

• 28.5% didn’t wash hands because ABHR not available

• 69% didn’t wash hands because just went into room to talk

• 52% rarely to never got personal feedback regarding practice of HH

Average Percent of Compliance = 40%

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Infection Control and Hospital Epidemiology July 2010 Vol.31, NO.7HH in LTCF: A Multicenter Study of Knowledge, Attitudes, Practices and Barriers

Are We Compliant with Hand Hygiene

Reasons For Non Compliance

1. Inaccessible products

2. Skin irritation

3. Too busy

4. Glove use made it unnecessary

5. Didn’t think about it

6. Lacked knowledge

THE ROLE OF HAND HYGIENE

Potential Advantages of Alcohol-based Hand Rubs (ABHR)

• Requires less time than hand washing

• Acts quickly to kill microorganisms on hands

• More effective than hand washing with soap and water

• More accessible than sinks

• Less irritating to skin than soap and water and can even improve condition of skin

THE ROLE OF HAND HYGIENE

Are the recommendations for ESBL in LTCFs to isolate only when symptomatic?

• Yes

• No

• We are not allowed to isolate our residents

• I have no idea

Recommendations for transmission-based precautions

Recommendations for transmission-based precautions cont’d

Resident characteristics to consider – “the 5 C’s”

• Cognitive function (understands directions)

• Cooperative (willing and able to follow directions)

• Continent (of urine or stool)

• Contained (secretions, excretions, or wounds)

• Cleanliness (capacity for personal hygiene)

Kellar M. APIC Infection Connection. Fall 2010 ed.

Essential Practices

• Adhere to Standard Precautions continuously

– Use gown and gloves if potential contact with blood/body fluid, non-intact skin or mucous membranes

• Includes urine, feces, wound drainage

– Perform hand hygiene before and after all contact with resident and the environment

– Perform hand hygiene after glove removal or changing gloves when moving from a dirty body site to a clean body site

A resident has active shingles and is in a semi-private room with a roommate. Should one of the residents

move to a private room and if so which one?

• No, shingles is not contagious

• Yes, the roommate should move

• Yes, the resident with shingles should be moved

• Not really sure what to do

Key points to remember

Herpes zoster, also known as zoster and shingles is caused by the reactivation of the varicella zoster virus, the same virus that causes chickenpox

People with herpes zoster, most commonly have a rash in one or two adjacent dermatomes (localized zoster); usually on the trunk along a thoracic dermatome. Does not usually cross the body’s midline

The rash can affect three or more dermatomes, a condition known as “disseminated zoster”; also defined as “appearance of lesions outside the primary or adjacent dermatomes”

CDC Recommendations

A=airborneC =contact

DI=duration of infection

CDC Recommendations

• Shingles cannot be passed from one person to another

• The virus that causes shingles can spread from a person with active shingles to cause chickenpox in someone who had never had chickenpox or received the chickenpox vaccine

• Lesions are infectious until dry and crusted

• To prevent healthcare associated spread, should ensure that all healthcare personnel have evidence of immunity

• CDC recommends shingles vaccine (Shingrix) for people aged 50 years or older

Documentation of age appropriate varicella vaccinationLaboratory evidence of immunity or diseaseDiagnosis by a healthcare providerBirth in US before 1980 (not for HCP)

So, for PPDs for residents, is it true that everyone on admission has to have a 2-step done and they

have to be exactly 2 weeks apart?

• No, residents only need a one-step PPD

• They no longer need to have a TST because they of their age

• Yes

• Not sure what they need

For employees, all have to have a 2 step and they have to be a week apart, correct?

• Yes

• No

• Not sure what they need

Determine your risk classification

NC TB Manual

10A NCAC 41A .0205 Control measures -tuberculosis

https://www.ncala.org/10A-NCAC-41A-0205-Control-Measures-Tuberculosis.pdf

What about frequency?

Residents in Long Term Care:Screening based on risk assessment

DFS requires annual screening which can be accomplished by a verbal elicitation of symptoms

Long Term Care Facility Employees: Screening based on risk assessment

DFS requires annual screening which can be accomplished by a verbal elicitation of symptoms

We will be receiving our flu vaccines on 9/26/18. I have heard different things on when to give the vaccines:as soon as you receive or wait until 10/1/18. I am wondering when is the best time to give them?

• Flu vaccine should not be given until October 1st

• Give flu vaccine as soon as you get you supply

• You can give anytime, does not matter

“Just the facts, ma’am”

Protection from flu vaccination

sets in after 2 weeks.

CDC recommends getting flu vaccine by the end of October, however getting vaccinated later is still beneficial and should be offered throughout flu season

Vaccines available:• Nasal spray flu vaccine (non-pregnant individuals and use in 2-

49 years of age)• Trivalent vaccine• Quadrivalent vaccine• High dose (Fluzone) for 65 and older• Shot with adjuvant (FLUAD) 65 and older

https://www.cdc.gov/flu/protect/keyfacts.htm

Do we still have to offer the influenza immunization if the resident declined last year?

• No, the resident and/or family has to ask for the vaccine

• Yes and tell them they have to take it this year

• Only if the resident has respiratory signs and symptoms

• Yes after providing education

F883 §483.80(d) Influenza and pneumococcal immunizations

Influenza. The facility must develop policies and procedures to ensure that-

• (i) Before offering the influenza immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization;

• (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;

• iii) The resident or the resident’s representative has the opportunity to refuse immunization; and

• (iv)The resident’s medical record includes documentation that indicates, at a minimum, the following: – (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects

of influenza immunization; and

– (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

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What is an approved cleaner for glucometer machines? How long should the machine be

wrapped?

• If the glucometers are dedicated to a single resident they do not need to be cleaned

• Glucometers used on multiple residents should be cleaned daily and kept wrapped for at least one minute

• Always use a bleach wipe to clean glucometers

• Follow the manufacturer’s guidelines and recommendations

We use dedicated glucometers for our residents. Can we store them on the medication cart?

• Absolutely

• No I don’t think so

• Actually I am not sure

• No the family needs to take home and bring back

What is the big deal?

Outbreaks of HBV (2 or more cases) reported to CDC 2008-2016• 18/24 (75%) of Hepatitis B outbreaks

occurred in LTCF• 15/18 (83%) associated with ABGM• 1,680 exposed• 133 persons infected

What is the big deal?

Five outbreaks of viral Hepatitis (B and C) between 2001-2012• 4/5 in extended care• 3/4 identified ABGM• 1704 exposed• 36 infections• 6 deaths

https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html

https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm227935.htm

Who should be involved at the facility if new construction and/or renovation is taking place?

• Director of Nursing, Administrator, Construction staff

• Medical Director, Construction staff, Administrator

• Construction staff, infection prevention, DON, Administrator

• Director of Nursing, construction staff

CONSTRUCTIONINFECTION CONTROL RISK ASSESSMENT (ICRA)

When is this necessary?

• New construction

• Renovation – Painting

– Changing carpet

• Water damage (clean or dirty)

• Mold remediation

• Asbestos removal

• HVAC replacement

Infection Preventionist

should be involved from the VERY

beginning…

Construction risk assessment elements

Step 1: Identify type of project

Excerpt obtained from http://www.ashe.org/resources/tools/pdfs/assessment_icra.pdf on 8/3/18

Construction ICRA elements

Step 2: Identify resident risk groups

Excerpt obtained from http://www.ashe.org/resources/tools/pdfs/assessment_icra.pdf on 8/3/18

Construction ICRA elements

Step 3: Create matrix to determine class of precautions required

Excerpt obtained from http://www.ashe.org/resources/tools/pdfs/assessment_icra.pdf on 8/3/18

Construction considerationsKEY elements to ensure resident safety

Dust control (HVAC, sticky mats, mopping, vacuuming, etc.) Plastic and/or hard wall barriers (based on length of

project) Limited ceiling tile removal permits Re-location of residents during project Interruptions to water, plumbing, power, etc. Re-location of patient care equipment, supplies, etc. Proper transport of construction debris (covering & route) Terminal cleaning and preparation for opening the area

MONITOR for COMPLIANCE!!!

Questions?

Un-mute your line Type in the chat box

Resources

https://www.ncala.org/10A-NCAC-41A-0205-Control-Measures-Tuberculosis.pdf

https://www.cdc.gov/flu/protect/keyfacts.htm

https://www.spice.unc.edu

http://www.ashe.org/resources/tools/pdfs/assessment_icra.pdf

ReferencesStatewide Program for Infection Control & Epidemiology (SPICE)

https://spice.unc.edu/

North Carolina Communicable Disease Rules: Title A-Health

and Human Services, Chapter 41 Epidemiology Healthhttps://www.ncala.org/10A-NCAC-41A-0205-Control-Measures-Tuberculosis.pdf

Centers for Disease Control & Prevention (CDC)https://www.cdc.gov/flu/protect/keyfacts.htm

Centers for Medicare & Medicaid Services (CMS)https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

THANK YOU FOR YOUR ICAR PARTICIPATION AND SUPPORTING

RESIDENT SAFETY!

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