LTC-CIP Learning System Module 1 PDF

Proprietary Rights Notice © 2023 Association for Professionals in Infection Control and Epidemiology and/or its licensor(s). All rights reserved. No part of this Publication may be reproduced or distributed without the express permission of Association for Professionals in Infection Control and E...

Proprietary Rights Notice © 2023 Association for Professionals in Infection Control and Epidemiology and/or its licensor(s). All rights reserved. No part of this Publication may be reproduced or distributed without the express permission of Association for Professionals in Infection Control and Epidemiology (“APIC”). You may only use this Publication for personal, noncommercial educational purposes if you are provided access to this Publication pursuant to a license between you and APIC. ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY, APIC, and all other names, logos, and icons identifying APIC and its programs, products, and services are proprietary trademarks of APIC, and any use of such marks without the express written permission of APIC is strictly prohibited. For additional permission or license rights to use the Publication, contact [email protected]. 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APIC makes no representation with respect to, nor does APIC guarantee or endorse, the quality, non-infringement, accuracy, completeness, timeliness, or reliability of any third- party materials, information, services, or products. The use of such sites is entirely at your own risk. No Legal or Medical Advice The Publication is provided for informational purposes only. APIC does not offer legal or medical advice. Nothing contained in the Publication is to be considered as the rendering of legal advice or medical diagnosis or treatment. The Publication must not be relied upon in substitution for the exercise of independent judgment, or for the legal advice of an attorney or medical advice of a qualified health provider. Acknowledgments APIC acknowledges the following subject matter experts for their contributions to the development of the APIC LTC-CIP Learning System Content Development Subject Matter Experts Linda Behan, BSN, RN, CIC Evelyn M. Cook, RN, CIC President, Infection Prevention and Control Associate Director SPICE Long-Term Care Infection Prevention, LLC University of North Carolina at Durham Glen Mills, Pennsylvania Durham, North Carolina Deb Burdsall, Ph.D., RN-BC, CIC, LTC- Jacqueline L. Whitaker, RN, MS, CPHQ, CIP, FAPIC CPHRM, CIC, FAPIC Infection Preventionist IP Education Specialist Team Lead Baldwin Hill Solutions LLC Florida Department of Health Palatine, Illinois Tampa, Florida Item Development Contributors Katherine Anderson, MPH, MBA, CIC Dr. Maria Macedo-Rea, DNP, MPH, CIC, Fibi Attia, MD, MPH, CIC CPHQ Christine Ann Bingman, DNP, RN, CIC Joi McMillon, RN, BSN, MBA, CRRN, WCC, CJCP, HACP-CMS, CIC Mary L. Cole, RN, MS, CNRN, CCRN, SCRN, CIC Suzanne Ames Moreshead, MBA, BSN, RN, CIC Megan Crosser, BS, MPH, CIC April T. Parsons, RN, BSN, CIC Elyse K. Fritschel, MPH, CIC Janet L. Riese, MSN, BSN, CIC Paul M. Gentile, MPH, CIC Marian P. Salamon, RN, CIC Elham Ghonim, Ph.D., MLS (ASCP), CIC, CPPS, CPHQ, LSSGB, FAPIC Renee M. Savage, MPH, BSN, RN, CIC Linda R. Greene, RN, MPS, CIC, FAPIC Sheila D. Shipley, DNP, RN, CIC Lisa Hannah, RN, CIC, BS Donna Spangler, RN, MPH, CIC Ahmed Hassaballa, MD, CIC Kim Strelczyk, RN, MSN, CIC, FAPIC Teri Hulett, RN, BSN, CIC, FAPIC Lisa Vitale, MSN, RN, CIC Kim Long, RN, CIC Jacqueline L. Whitaker, RN, MS, CPHQ, CPHRM, CIC, FAPIC  Introduction to the APIC Learning System for LTC- CIP™ According to Centers for Disease Control and Prevention (CDC) estimates, more than 1.3 million individuals in the United States received supportive care in nursing homes in 2016. Other long-term care (LTC) providers, including hospices and residential care communities, provided care for at least 2.2 million individuals. These types of facilities will continue to grow in importance, as the CDC also estimates that the number of Americans over 65 will nearly double— and the number of those over 85 will triple—by 2050. In any healthcare facility, healthcare-associated infections (HAIs) can result in considerable harm or death for patients. Efforts to prevent the spread of HAIs take many forms, but they always rely on foundational scientific principles enshrined in infection prevention and control programs. Because HAI programs generally have been developed with acute care in mind, LTC facilities may struggle to keep patients safe while adapting infection prevention practices to the resident population. This can create infection prevention and control challenges, especially considering that the characteristics of residents in LTC facilities put them at higher risk of severe outcomes associated with HAIs. Several features of the care setting may also increase the risk of HAI transmission. First, staff often assist residents with routine daily care activities when the residents may not be able to handle these things themselves. Staff and other residents are the primary sources of social interaction for LTC residents, which makes communal events a necessary care consideration. Further, LTC residents may live in spaces that contain more personal items to suit their need for an appropriate home-like care setting. In order to prevent HAI transmission in this population, federal regulations in the United States require LTC facilities to have a designated infection preventionist (IP) on staff. The IP may have many varied responsibilities and requirements depending on the facility’s size, location, resident population, and other factors. The role may be the singular focus of a staff position, or it may be one of many duties assigned to an individual. To satisfactorily fulfill the required duties of the infection preventionist, individuals are encouraged to seek professional certification, such as the Long-Term Care Certification in Infection Prevention (LTC-CIP) of the Certification Board of Infection Control and Epidemiology (CBIC). Certification signals that the IP has mastered the knowledge of infection prevention and control and is committed to professional growth. Given the wide range of responsibilities and facilities that are encompassed by CBIC’s LTC-CIP, candidates seeking certification must demonstrate a wide base of standardized basic knowledge, skills, and abilities. This APIC Learning System for LTC-CIP™ is designed by the Association for Professionals in Infection Control and Epidemiology (APIC) to build on LTC-CIP exam candidates’ educational and professional experience, ensuring that all candidates who meet the necessary requirements to sit for the LTC-CIP exam understand all components of the exam focus areas well enough to both pass the exam and adequately perform the duties of the IP as needed by their facility. About APIC With more than 15,000 members, APIC is the leading professional association for IPs. Our mission is to advance the science and practice of infection prevention and control. Most APIC members are nurses, physicians, public health professionals, epidemiologists, microbiologists, or medical technologists who:  Collect, analyze, and interpret health data in order to track infection trends, plan appropriate interventions, measure success, and report relevant data to public health agencies. Establish scientifically based infection prevention practices and collaborate with the healthcare team to assure implementation. Work to prevent HAIs in healthcare facilities by isolating sources of infections and limiting their transmission. Educate healthcare personnel and the public about infectious diseases and how to limit their spread. Many IPs are employed in healthcare institutions and also serve as educators, researchers, consultants, and clinical scientists. APIC members practice in various care settings, including long-term, acute, ambulatory, and outpatient care, where they direct programs that protect patients and personnel from HAIs. To learn more, visit apic.org. Module 1: Long-Term Care Settings Infection prevention efforts in long-term care settings are crucial to the health of residents, staff, and visitors alike. However, in order for such efforts to be successful, infection preventionists must first understand the nature of the settings they are in charge of. The term “long-term care” may apply to many different types of facilities, depending on the facility location and the understanding, education, and expertise of the individual using the term. With that necessarily comes a wide range of care team members and service offerings, all of which impact and are impacted by infection prevention plans and efforts. To avoid confusion related to the wide range of meanings on this front, Section A starts with a discussion of the long-term care facility itself, including what specific facility types we refer to throughout this product, the members of the care team, and the services rendered in these facilities. From there, Section B discusses the ethical issues that are common in these facilities, including how they apply to non-physician members of the care team and how the infection preventionist (and others within the facility) can raise ethics questions that require expert assistance to navigate. Section C moves into discussions of some common groups of residents in long-term care facilities. It also looks at common medical devices used by these groups and the specific infection risks associated with them. Finally, Section D moves into a discussion of the expansive web of regulatory entities that affect long-term care facilities. Depending on the facility’s geographical location and specific classification, any number of governmental entities may have regulating authority. Other entities do not regulate or may not have regulatory authority over a facility but still may be a valuable and important resource for recommendations and guidance. Section A: Long-Term Care Facilities After completing this section, learners will be able to: Understand and explain the importance of infection prevention and control in long-term care (LTC) settings. Recognize the different services that LTC facilities offer as well as those services that can be provided by contractors. Identify the members of a resident’s interdisciplinary team and identify how they may assist with or be affected by the infection control plan. Long-term care facilities may cover a wide range of types. Topic 1: Long-Term Care and Infection Prevention The wide variety of long-term care facilities provide care to individuals who need assistance with self-care activities. These facilities have a specific and important need for infection prevention. Long-Term Care Long-term care (LTC) generally refers to the large range of facilities that provide care to individuals unable to achieve independent self- care. These facilities include nursing homes, skilled nursing facilities, and assisted living facilities. Long-term care encompasses the medical, physical, and psychosocial services necessary to support individuals living with chronic health problems. In addition to the traditional model, LTC provides memory support, respite care, hospice care, palliative care, and post-acute rehabilitation. Some LTC facilities also provide ventilator support and dialysis. These facilities tend, at least in the United States, to be for- profit businesses. They generally, but not exclusively, cater to older adults who are unable to care for themselves or otherwise have medical conditions that require consistent or constant support. LTC facilities typically function as the resident’s home, and the resident may require assistance in multiple areas—dressing, bathing, grooming, toileting, eating, and moving—all of which may require close and repeated contact between individuals employed or contracted at the facility and the resident. The level of support for individuals in these settings may range from cues, reminders, and other low-level assistance to serious interventions, including complex wound care and management of ventilator and dialysis support. Need for Infection Prevention Comprehensive infection prevention and control (IPC) programs are necessary in LTC. This need exists for multiple reasons, including the increasing complexity of skilled care provided in the LTC environment as well as a better understanding of the prevalence of residents who are colonized and infected with multi-drug-resistant organisms and how outbreaks, epidemics, and pandemics harm residents and healthcare personnel in LTC. The World Health Organization defines an IPC program as a “practical, evidence-based approach preventing [residents] and health workers from being harmed by avoidable infections.” This need is exacerbated by multiple different factors that may be at play in any given LTC environment, including but not limited to: Normal aging processes.  Increased likelihood of co-morbidities and device use compared to those living independently. Cost focus leading to detrimental effects. As of 2019, the United States Centers for Medicare & Medicaid Services (CMS) has required facilities that fall under its regulatory authority to have an infection preventionist (IP) on staff. APIC (the Association for Professionals in Infection Control and Epidemiology) defines these individuals as “professionals who make sure healthcare workers and [residents] are doing all the things they should to prevent infections.” Competent IPs should be able to: Apply scientific principles and methods to the collection and presentation of IPC data. Conduct surveillance following current and approved definitions of infection and standard methodologies for case identification, data collection, and reporting. Prepare reports and presentations for committees. Investigate outbreaks and implement infection prevention interventions. Report outbreaks of communicable diseases to county/state health departments as needed after consultation with the administration and the medical director. Plan and conduct educational programs. Develop and review policies and procedures and monitor their use to support optimal staff compliance and resident safety. Ensure compliance with county, state, and federal standards for infection prevention. Topic 2: Types of LTC Facilities Long-term care facilities share a common set of characteristics, affiliations, and ancillary service offerings. These topics are covered next. Facility Characteristics Long-term care facilities are described by the Centers for Disease Control and Prevention (CDC) as “facilities providing a spectrum of medical and non-medical supports and services to frail or older adults unable to reside independently in the community.” Many LTC facilities must deal with cost pressures. These pressures may be present in an LTC facility regardless of its mission or profit status. Cost pressures lead to many restrictions associated with and outcomes resulting from measures undertaken to save money, including: Multiple occupancy rooms. Shortage of licensed nurses and certified nurse’s aides. Low staffing ratios. High staff turnover. Presenteeism, where staff are encouraged or pressured to work while sick. Poor or nonexistent training programs for staff.  Use of cheaper, less effective cleaning products and systems. Supply restrictions. The infection preventionist (IP) can help drive person-centered care by developing and supporting an infection prevention and control program that promotes and incorporates cost-effective, evidence- based practices. Person-centered care is defined by the Centers for Medicare & Medicaid Services (CMS) as a “means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.” Similar to the presence of an IP on staff, a focus on person-centered care is required by the CMS for the facilities that fall within its authority to regulate. Key Point Practices focused on providing person-centered care can reduce the risk of infection and decrease the need for expensive and invasive treatments and procedures, reducing overall expenses for a facility. No matter if such practices are required by regulation or not, the IP can help drive this focus through the implementation of an effective IPC program. The importance of a focus on person-centered care will continue to grow as the population of residents in LTC facilities in the United States is projected to grow over time due to population shifts, increasing life expectancies, and increased risk of physical and cognitive disabilities. Types of Long-Term Care Facilities and Facility Affiliations This learning system focuses on three main types of LTC facility: nursing homes, skilled nursing facilities, and assisted living facilities. Nursing homes. Nursing homes are defined by the CDC as: Nursing facilit[ies] providing primarily long-term maintenance and restorative care for individuals needing support with their activities of daily living. A large percentage of certified nursing homes in the U.S. provide a combination of long-term nursing care or restorative services and skilled nursing services. Skilled nursing facilities (SNFs). Skilled nursing facilities are defined by the CDC as: Facilit[ies] engaged primarily in providing skilled nursing care and rehabilitation services for residents who require such care because of injury, disability, or illness. A large percentage of SNFs are dually certified as both SNFs and nursing homes  In some states, these facilities may be called adult care homes. Two types of skilled nursing facilities that may pose specific challenges from an IP perspective are: Ventilator skilled nursing facilities (VSNFs). VSNFs are facilities that are able to serve individuals requiring short- or long- term mechanical ventilation. Many skilled nursing facilities will have their own ventilator units. Swing bed facilities. In the United States, the Social Security Act allows hospitals that meet certain criteria (small size, rural location) to enter into a swing bed agreement, which allows the hospital to use its beds to provide either acute care or skilled care, depending on need and availability. Assisted living facilities (ALFs). Assisted living facilities are defined by the CDC as: Facilities [that] provide help with activities of daily living (for example, taking medicine, using eye drops, getting to appointments, and preparing meals). Residents often live in their own room or apartment within a building or group of buildings. Key Point Note that each of these facilities may also provide care for persons with cognitive co-morbidities, such as dementia or Alzheimer’s disease, in addition to other services such as hospice care. The scope of service provided may vary, from dedicated facilities or facility wings for a specific disease, to simply providing care for residents with cognitive co-morbidities alongside other residents who are unaffected, and anything in between. IPs should also recognize and understand the differences among various other types of long-term care facilities: Pediatric long-term care facilities. This may include care for individuals with medically complex needs and developmental disabilities, which poses unique challenges for infection prevention. For example, IPs in these settings may need to create standards for cleaning toys that may be shared among children. Hospice and respite care facilities. Hospice and respite care can be provided at dedicated facilities or as offered services. (This learning system will discuss only hospice care in detail.) These facilities may focus on comfort care and end-of-life care. One of the challenges in respite care facilities is providing care for patients across shorter timelines with rapid turnover; these facilities may function largely to provide care when familial caretakers need a break or are out of town.  Long-term acute care. Long-term acute care facilities operate like hospitals and must have a hospital license. These facilities may have populations that pose similar challenges from an IPC perspective, such as caring for individuals on ventilators or dialysis. Others. Depending on state-specific designations, other facilities might include group homes and prisons, among others. Each of the facilities listed above may require similar IPC considerations as other LTC facilities. Typical Facility Affiliations Similar to how there are multiple types of LTC facilities, there are multiple different ways that these facilities may operate: Independent, freestanding Independent, continuing care retirement community Multi-facility organization (chain) Hospital system, attached Hospital system, freestanding Additionally, facilities may be state-run or privately owned and operated. Understanding the differences between these facility affiliations is unlikely to be crucial to successfully passing the LTC certification exam. However, the particularities may affect how you operate as an IP for your organization. For example, a multi-facility organization may have more shared internal resources or set operating procedures so that they can better ensure that each facility is operating in the same manner. A contrasting example would be an independent, freestanding facility, which may have fewer available resources and a simpler operating structure but may provide for easier access to leadership and improved communication channels. Understanding the type of environment your facility affiliation and ownership model creates is essential to your ability to perform your duties. Topic 3: Interdisciplinary Care Team and Service Provisions Just as LTC facilities provide a variety of care levels and have a variety of ownership models, they also provide a wide range of services and work with a wide variety of professionals to provide holistic care to residents. The services offered may be broken down into two groups: Typical services, which are widely offered, regardless of facility type Ancillary services, which may be less commonly offered or are usually provided by contractors The Interdisciplinary Team Interdisciplinary team (IDT) cooperation forms the basis of LTC. In Appendix PP of its “State Operations Manual,” the Centers for Medicare & Medicaid Services (CMS) defines interdisciplinary in the LTC setting to mean that “professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident.” When discussing the development of a comprehensive care plan, Appendix PP also indicates that an IDT must include but is not limited to: The attending physician. A registered nurse with responsibility for the resident. A nurse’s aide with responsibility for the resident.  A member of the food and nutrition services staff. The participation of the resident and the resident’s representative(s) to the extent practicable. The above list gives us a good place to start with regard to the required members of the IDT. However, as Appendix PP shares, other staff members may function as part of the interdisciplinary team as well. Richard Stefanacci and Corey Cusack provide a more expansive list and descriptions (with regard to SNFs), published in Annals of Long- Term Care. The positions and their descriptions are summarized in Exhibit 1-1: Exhibit 1-1: Interdisciplinary Team Members in Long-Term Care IDT Member Position Description Nursing home Functions as the managing officer of the facility, responsible for administrator directing and executing day-to-day functions and maintaining LTC facility compliance with legal requirements. Medical director A required position in certain facility types, responsible for physician leadership, patient care and clinical leadership, quality of care, and education. Attending primary Responsible for initial patient care and supports discharges and care physician transfers. May not be present daily in a facility but periodically visits to ensure that residents are receiving sufficient medical care. Physician assistant Coordinates patient treatment between multiple parties, including the (PA) primary care physician, the patient, and patient families (when applicable).  IDT Member Position Description Nurse practitioner Advanced practice nurse who provides high-quality services, including diagnosis and treatment of a wide range of conditions in lieu of a physician. Consultant Reviews and manages medication regimens for residents, including pharmacist ensuring that medications are appropriate, effective, safe, and correctly used. Podiatrist Specialist with regard to the foot and ankle; may specialize in more detailed subcategories of care such as surgery or diabetic care. Psychologist Responsible for providing mental health treatment and support for residents, including for conditions such as depression, anxiety, and dementia. Wound care Specialist trained to treat wounds caused by injury, surgery, diabetes, specialist sores, and slow-healing wounds. May be a nurse, a physician, a physical therapist, or other medical professional. Dietitian Individual responsible for planning and execution of food and nutrition programs, including the supervision of food preparation and meal service. Certified nurse’s Works under the supervision of a nurse to assist residents with daily aide (CNA) living tasks. Registered nurse Functions as the primary contact point between a resident and other (RN) members of the healthcare team; responsible for resident evaluations, common procedures, monitoring vital signs, and administering medications. Licensed practical Nurse who reports to physicians and RNs and is responsible for highly nurse personal care of residents. Depending on the state, may administer medicines or start IVs. Director of nursing Oversees standards of nursing practices for all organizational nursing (DON) services. Registered nurse Assists the DON with making sure that the facility complies with state assessment and federal guidelines and coordinates processes associated with coordinator assessing residents and the interdisciplinary care process. (RNAC) Infection Plays a key role on the IDT by minimizing the incidence of healthcare- preventionist associated infections and transmission of illnesses between residents.  IDT Member Position Description Physical therapist Focuses on physical rehabilitation (including increasing strength, flexibility, range of motion, and motor control and reducing pain, swelling, and discomfort) of issues caused by injury or illness. Occupational Focuses on improving residents’ ability to complete daily tasks therapist associated with their normal life, including assisting with issues arising from mental, physical, developmental, and emotional sources. Recreational Uses artistic, creative activities and/or physical activities to improve the therapist physical, mental, and social well-being of residents. Social worker Assists individuals through issues related to relationships and other personal and family problems. Speech language pathologists also play an important role in LTC facilities by helping residents with speech, language, social communication, cognitive-communication, and swallowing disorders. As evidenced by the breadth of these positions, members of the IDT assist with a wide range of issues based on a diverse set of needs and considerations. Note that the IDT may change over time and be different from resident to resident, based on the residents’ individual needs. Key Point The changing nature of a resident’s IDT over time and the variation of the IDT from resident to resident both pose challenges from an infection prevention perspective, as the infection preventionist needs to ensure that all IDT members involved in care for residents at their facility follow good infection prevention practices. However, it is important to note that other issues related to IDTs play a role too. High rates of staffing turnover, especially among staff that are responsible for direct care of residents and environmental cleaning and disinfection, may cause complications and difficulty in ensuring that good infection prevention practices are followed. Similar difficulties may be caused by staffing shortages, which can result in a poor ratio of licensed to unlicensed caregivers and the facility staff being made up of staff members who are insufficiently qualified for their position. Many members of the IDT help provide or otherwise interact with the various ancillary services that may be common to LTC facilities. These services are discussed next. Typical Services Services that are typically offered in LTC settings include long-term general nursing, long-term dementia care, skilled nursing or short- term care (such as subacute rehabilitation), and hospice and palliative care. These services are largely provided by nursing and other healthcare staff directly employed by the LTC facility. Exhibit 1-2 lists these particular services as well as other typical, though potentially less common, services. Exhibit 1-2: Typical Services in LTC Facilities Service Description  Service Description Long-term general This consists of the provision of general health services and preventive nursing care, along with health education, within an LTC facility. Focused and comprehensive assessments of residents are performed by licensed nursing staff, while other resident support is provided under the supervision of an interdisciplinary team of nurse’s aides, dietary staff, and activity aides and professionals. This requires an understanding of both the individual resident and the aging process so that changes in the resident’s condition can be rapidly identified and addressed by nursing staff and physicians. Long-term This consists of caring for persons with dementia, which poses dementia specific challenges as residents may be unable to describe how they care/memory are feeling. These residents may require additional hygiene and other support support, though they may generally be of stable health beyond cognitive defects. Skilled nursing This refers to care for individuals who enter an LTC facility for a short period of time and/or to transfers between healthcare facilities. Many facilities have short-term units for individuals who come to recover and undergo rehabilitation after medical or surgical procedures. These facilities are sometimes referred to as transitional care units (TCUs), and must follow long-term care regulations.  Service Description Hospice and Hospice and palliative care both focus on care, comfort, and quality of palliative care life for sick individuals. However, they refer to slightly different concepts. Hospice care is defined by the Centers for Disease Control and Prevention (CDC) as “a program of [comfort] and supportive care service providing physical, psychological, social, and spiritual care for dying persons, their families, and other loved ones.” Typically this occurs when a patient is expected to live six months or less. It is important to remember that although this may result in cessation of treatments designed to cure a disease, that does not mean that treatments to relieve pain and other issues also cease. Hospice care occurs at four general levels: routine home care, respite care, continuous care, and general inpatient care. Palliative care is defined by the World Health Organization (WHO) as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, [including psychological], psychosocial and spiritual.” This type of care may be extended to “debilitating illnesses” instead of those purely considered life-threatening. Note that the definitions for these terms may differ from place to place, though the intent is clearly the same: to plan for and provide care that supports the patient’s (or resident’s) goals, desires, and needs while managing the patient’s pain and other symptoms as they progress through their disease process toward the end of life. Long-term This type of care addresses mental illnesses, such as depression and psychiatric (non- anxiety along with other psychiatric disorders. These diseases, if dementia) care untreated, can lead to higher infection risk due to risky behaviors. Respiratory and Individuals requiring short- or long-term mechanical ventilation are ventilator support faced with many additional infection risks, requiring knowledgeable management and care from staff. Bariatric care Bariatric care involves care for individuals with obesity, which increases the risk of certain chronic conditions and may require special nutritional considerations. It also may require the use of special equipment and processes and may involve caring for individuals following bariatric surgery.  Service Description Dialysis This includes care for individuals requiring medical assistance to (hemodialysis [HD] replace the normal function of the kidneys, using artificial and peritoneal (hemodialysis) or natural (peritoneum dialysis) membranes to filter out dialysis [PD]) certain molecules while allowing others to pass through. This requires special considerations and requirements with regard to patient ports, water management, and care of dialysis machinery. Ancillary Services Ancillary services—including food and nutrition, personal care, and environmental services as well as others—are offered in addition to the typical services provided in LTC facilities. Members of the IDT are in charge of many of these services. These services are often (though not always) offered via contractors, involving individuals external to the facility. The inclusion of these individuals and the nature of the services themselves often require special considerations and coordination efforts by the IP. Food and Nutrition Food and nutrition services play a critical role in the LTC environment. This category comprises multiple sub-services and considerations. Examples of these considerations include: Food handling, preparation, and storage. Cleaning, sanitation, and maintenance of food preparation areas, utensils, and equipment by food and nutrition staff, nursing staff,  and life enrichment staff. Dietitians, to plan appropriate meals/diet based on the medical and health requirements of the residents. Accounting for the health and safety of residents and staff along with visitors. Personal Care Life enrichment activities work to achieve a person-centered model of care. This involves a multitude of potential services, discussed in more detail in Exhibit 1-3. Note that the baseline requirement for successful IP management of these and all other ancillary activities begins with communication. Exhibit 1-3: Personal Care Services in Long-Term Care Service Description Podiatry Podiatry, as a medical service, is usually offered to older adults and individuals with diabetes. Typically, any service that goes beyond nail cutting and removal of toenails (including ingrown toenails) would be offered in a clinic instead of in an LTC facility, although nail fungal infections may be prevalent in geriatric residents and may be treated in an LTC facility as well. Some facilities may allow only podiatrists to cut residents’ toenails. Dental Dental practitioners may visit LTC facilities to provide general dental care for residents, which often includes cleaning, fillings, and denture work. More extensive work, such as oral surgery, is out of scope for LTC facilities.  Service Description Hair care and Individuals providing salon and barber services may be subject to salon services licensing by both state and local entities, which includes guidelines and regulations with regard to cleaning, safety, chemical use, criteria for disposable products, and other areas. No matter if the services are internally run by the facility or contracted out, personnel must conform to the constraints provided by their training and/or licensure. Services provided in the LTC facility might also include nail care and hygiene, potentially in the form of manicure services (although these can also be offered by volunteer or recreational staff). These may also be subject to specific licensing requirements. Vision Optometry services may be provided to individuals in long-term care to help with vision concerns. Depending on the agreement with the service provider, on-call or after-hours services may be provided, along with routine eye exams and subsequent prescription and supply of glasses. Environmental Services Environmental services are important due to the increasing and changing use of LTC facilities and the movement of residents across care settings. Environmental services focus on cleaning the facility, including high-touch surfaces (such as knobs and handles on medical equipment, bedrails, TV remotes, light switches, and telephones) and low-touch surfaces (such as floors, walls, window curtains, lights, and ventilation grills). Environmental service activities lower the number of organisms present on surfaces, which in turn helps in the control of infections. Facility policies (pursuant to applicable laws and regulations) specify what must be cleaned and how frequently, although compliance with facility policies may be problematic. Other Services Other ancillary services are described in Exhibit 1-4. Exhibit 1-4: Other Ancillary Services in Long-Term Care Service Description Animals Animals in LTC facilities can help decrease loneliness, increase socialization, and provide companionship, improving the quality of life of residents while posing additional disease transmission risks. These programs may include use of facility animals or companion, therapy, or service animals and visits by personal pets. Intergenerational LTC facilities are not isolated from the rest of society; instead, they and group activities exist within the larger social community. Intergenerational activities can benefit members of the community (enhancing development of children) as well as older adults, who benefit from increased connectivity. These activities may include opportunities such as on-site day care facilities, school activities, arts and crafts classes, and religious groups. However, younger children may struggle to follow rules with regard to hygiene, which causes increased risk of infection to everyone attending the activity. Pharmacy services Pharmacy services may dispense, deliver, and administer medication to the LTC facility and its residents. The IP in the LTC facility must ensure that the pharmacy partners follow and participate in antimicrobial stewardship activities and that they have antimicrobial prescribing expertise. PICC teams Dedicated teams that have expertise with peripherally inserted central catheters (PICC) may be used in LTC facilities to help reduce the risk of bloodborne infections and help IPs with infection prevention, surveillance, and other crucial activities. PICC teams can also provide assistance with dressing changes or staff education related to catheters. The PICC team may be a contracted service in an LTC facility. Laboratory LTC facilities in the U.S. typically do not have lab services, although a services facility may make use of a hospital laboratory if available through part of a larger health system. Otherwise, use of private lab services will be necessary. The LTC facility must be aware of the laboratory service’s capabilities and lead times along with their rules on specimen collection and transportation.  Service Description Laundry services LTC facilities must clean residents’ clothing and provide clean linens. Depending on the facility, laundry services may make use of a variety of carts, shelves, tables, laundry chutes, washers, and dryers. Facilities must also have a physical barrier between areas for clean and soiled linens. Radiologic services LTC facilities will not have their own in-house radiological services. However, the IP must be familiar with radiological reports, which can be an important source of surveillance data. In addition, radiology staff need to follow infection control practices. Rehabilitation and Rehabilitation and physical therapy services are key to resident health physical therapy and happiness, and they help residents attain and maintain the best practical well-being with regard to physical, mental, and social health. These efforts may comprise many separate services, including therapeutic recreational services; physical medicine; speech and audiology services; care for amputees and prosthetic services; and sensory aids. The services may occur in group settings or in individual resident rooms. Respiratory therapy Respiratory therapy includes procedures to monitor and support respiratory function. Such procedures may include the administration of medical gases and aerosolized medications, bronchial hygiene therapies, airway management procedures, lung expansion therapies, mechanical ventilation, and blood gas sampling and analysis. As each of these procedures is a potential source of infection for the resident or provider, respiratory therapists must follow infection control practices. Transportation In order to transport residents with limited mobility or who require wheelchairs, LTC facilities may use transportation contractors or volunteers or have their own vehicles and drivers. Volunteers Volunteers may be used in LTC facilities to perform the same or similar tasks as LTC facility staff. Section B: Ethics After completing this section, learners will be able to: Understand ethical issues and challenges that relate to providing long-term care. Incorporate ethical principles into the design and execution of infection prevention and control programs. Identify key stakeholders involved in ensuring that LTC facilities adhere to correct ethical standards. Ethical issues are common in LTC facilities, and applying ethical principles correctly and seeking expert guidance in navigating these issues are of the utmost importance. Topic 1: Basic Ethical Principles Ethical principles play a key role in any healthcare environment, and this includes LTC facilities of all types and sizes. In certain situations, such as outbreak response, health workers, including those in LTC facilities, have general ethical duties to reduce morbidity and mortality through provision of the highest quality healthcare possible, as is described by O. le Polain de Waroux and D. G. Bausch, in the “Response to an Outbreak” chapter in Control of Communicable Diseases Manual. However, there are additional ethical principles that LTC facility staff should follow during their daily duties. Ten Ethical Principles In a May 2005 article for Annals of Long-Term Care, Fred M. Feinsod and Cathy Wagner describe ten ethical principles that apply in geriatric and long-term care settings: Beneficence. This principle refers to focusing on the welfare of the patient and doing what is right, and medically helpful, for them. Non-maleficence. This refers generally to avoiding harm. With regard to elderly patients and those in LTC facilities, it refers to using non-hospital treatments to avoid complications and unnecessary exposure to environments that contain infectious agents different from the resident’s typical environment. It also means avoiding the use of diagnostic procedures and treatments where the result is not likely to provide meaningful benefits to the patient in terms of well-being or survival. Futility of treatment. This concept is somewhat similar to the above principle, as it indicates that interventions should be avoided if they are not beneficial to the patient or may prolong the patient’s suffering. It requires that the physician and medical staff assess each patient and treatment option individually, ensuring that the treatment is consistent with the patient’s goals and that the issues have been made clear to the patient. Note that the patient’s goals must be clinically realistic for treatment to be consistent with them. Confidentiality. Patients must be provided complete and absolute confidentiality throughout treatment. This includes compliance with state and federal laws with regard to the disclosure of information to public health authorities and other interested or third parties. Autonomy and informed consent. Patients must be provided the right of self-determination, which includes the right to consent to or refuse diagnostic and treatment procedures. In order for consent to be considered informed, the patient must be educated on the pros and cons of a medical decision. The education concept applies to the use of an advance directive (discussed later). In order for autonomy to be faithfully executed, patients must have the mental capacity to make a decision, based on the complexity of the decision. If the patient does not have this capacity or their wishes are otherwise unknown, surrogates may make the decision. There are limits to this concept. When patients request care that would violate the standards of appropriate medical interventions or go against what is considered good medicine, this principle does not apply. It also does not apply where a patient makes a request in violation of legal requirements or that jeopardizes public health or safety. Additionally, the principle of autonomy may vary based on cultural values; use of a surrogate decision maker may be culturally appropriate even if the patient otherwise is capable of deciding on their own. Physician-patient relationship. According to this principle, patients should be allied with physicians and medical personnel with regard to their treatment goals and processes. This requires trust and fidelity between the two parties, along with adherence to other concepts within these principles, including education, confidentiality, and protection from intended harm. Where a conflict of interest exists, this should be disclosed to the patient. Truth telling. In order for patients to make accurate decisions, they must have the full truth surrounding their situation. Care should be taken to avoid the use of incomplete statements designed to encourage the patient or the use of confusing or technical medical terminology to hide the truth. Justice. Simply put, this refers to ensuring that resource allocation and provision of treatment are done fairly and equitably, in accordance with the law. All decisions made should be based on objective decision-making processes that avoid subjective and emotional influences. Non-abandonment. As the name indicates, a physician should not abandon the patient once a therapeutic relationship has been created. This does not mean that the physician cannot change the relationship. The physician may terminate the relationship as long as the patient or their proxy has been informed and allowed enough time to make other treatment arrangements, which the physician may be asked to assist with. If a conflict arises between the patient or proxy and the physician, it can be escalated to an ethics committee, ombudsman/ombudsperson, and/or appropriate governmental agencies for guidance. Limited resources. This concept relates to the reality that healthcare resources are limited and that situations may arise where treatment decisions must be made to allocate those resources. As described in the discussion of the justice principle,  these decisions should be made using objective decision-making processes that avoid discrimination and emotional influences. Key Point Note that many of the above principles are described as relating to physicians and patients. However, they are applicable to any employees in an LTC facility that come into contact with residents or their medical information or that are otherwise responsible for providing care to residents. This may include LTC facility staff having a duty to escalate their observations to the patient’s physician, for example, if they observe a treatment that is causing unexpected harm to the resident. Other Important Concepts Other important concepts with regard to ethics are listed in Exhibit 1- 5. Exhibit 1-5: Other Important Ethical Concepts Concept Description  Concept Description Durable power of Laws and definitions regarding power of attorney, including durable attorney power of attorney (DPA), may vary. However, the National Cancer Institute at the National Institute of Health (NIH) provides a clear definition of a DPA that explains both concepts and how they are related: A type of power of attorney. A power of attorney is a legal document that gives one person (such as a relative, lawyer, or friend) the authority to make legal, medical, or financial decisions for another person. It may go into effect right away or when that person is no longer able to make decisions for himself or herself. A durable power of attorney remains in effect until the person who grants it dies or cancels it. It does not need to be renewed over time. Also called DPA. Advance directive The advance directive is defined by the Centers for Medicare & Medicaid Services (CMS) as: A written instruction, such as a living will or durable power of attorney for healthcare, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of healthcare when the individual is incapacitated.  Concept Description Using precautions Regulations from the CMS and the Centers for Disease Control and in the least Prevention (CDC) task LTC facilities with providing the least restrictive restrictive way environment to residents. This is generally understood to refer to transmission-based precautions, which are discussed in detail elsewhere. However, the concept has an ethical component as well, as some of these precautions may involve issues such as who a resident is cohorted with, visitation rights, and what travel is allowed outside of the facility, among other issues. Guardianship Guardianship is defined by Zietlow et al. in an article published by the Journal of the American Geriatrics Society as: The legal process in which one individual takes over the decision making for another when it has been determined that the individual in question lacks decision-making capacity. The article defines different forms of guardianship, including full guardianship (pertains to authority for decisions in multiple areas, including legal, financial, and healthcare), temporary guardianship (undertaken under urgent medical circumstances, requiring a follow-up hearing), and conservatorship (sometimes used interchangeably for guardianship, although it more typically is used to refer to authority over strictly financial decisions). As is the case with the durable power of attorney, the particulars of the terms, their meanings, and the legal powers and requirements associated with them vary from state to state.  Concept Description Resident rights in The U.S. HIPAA Privacy Rule applies to LTC facilities. It permits the regard to sharing of residents’ personal health information (PHI) under only two information sharing specific situations: Treatment purposes. PHI can be shared for the purpose of providing individual and preventive treatment. The latter includes instituting certain measures to control an infection/outbreak, for example, a vaccination/immunization program or contact precautions. Healthcare operations. If an infection has been identified in an individual or outbreak case who has spent time in more than one facility (for example, a recent transfer), then healthcare personnel may share pertinent information that can be used for quality assessment and improvement activities. In both cases, the CDC cautions, “Only the minimum amount of PHI necessary for the particular health care operations purpose may be disclosed.” Topic 2: Resources to Address Ethical Issues Various resources are available to employees in LTC facilities to help address ethical issues. Ethics Committees As described in Resolution E98 of The Society for Post-Acute and Long-Term Care Medicine, ethics committees fulfill two specific roles in LTC facilities: They function to guarantee the development, promotion, and protection of values. They create a channel for communication between the various members of an LTC facility that can help clarify ethical and legal issues, weigh fiscal issues, and guide decision making for complex issues. These roles are accomplished through offering a variety of functions to address ethical issues that arise. Again, these are described in Resolution 98 as: Policy development and review. Quality assurance activities. Education.  Resource for staff, clinicians, administration, patients, families, and community. Monitoring judicial decisions and legislative action. Consultation and review of case-specific dilemmas. In order for an ethics committee to function properly, members must be sufficiently trained and educated, and they must reflect the community the committee supports. The institution must be engaged with the committee, accepting information from the committee surrounding issues that have arisen. States’ Long-Term Care Ombudsman Programs In the United States, the federal Older Americans Act (OAA) mandates that each state operate a long-term care ombudsman (or ombudsperson) office, which is charged with a variety of tasks. Although specifics of the program are listed in the OAA and associated federal codes, we can look to another federal government resource for a more easily understood summary. According to a fact sheet published by the Administration of Community Living (ACL), a function of the Department of Health and Human Services: [A state’s] long-term care ombudsman program serves individuals living in long-term care facilities such as nursing homes, board and care (including assisted living), and  similar settings and works to resolve resident problems related to poor care, violation of rights, and quality of life. Ombudsman programs also advocate at the local, state, and national levels to promote policies and consumer protections to improve residents’ care and quality of life. The fact sheet goes on to explain that thousands of trained staff and volunteers visit LTC facilities regularly to monitor and report on issues they identify, assisting residents who may not otherwise have—or may not be aware of—a method to raise concerns about their treatment. Note that the OAA mandates that each state establish its own office to achieve specific regulatory requirements. This means that each state’s office may be set up differently and have different levels of authority. Some states may empower their office to do more than the regulatory minimums set out by the OAA. In executing their daily duties, the IP needs to know the specifics of the program that affects their own facility; specific details on a given state’s program will not be tested in the certification exam. The infection preventionist can work with the ombudsman or ombudsperson to help ensure that residents and families understand infection prevention and control steps. An example is a situation in which a resident on contact precautions is visited by family members who refuse to use personal protective equipment (such as masks) and those family members visit other residents. In this case, the family members are not following proper procedures. If, following education and meetings, the family still refuses to follow proper procedures, the ombudsman may be called on by the facility to help remedy the situation. Section C: Special Populations and Social Gatherings After completing this section, learners will be able to: Differentiate between the types of medical equipment used in LTC facilities. Recognize and identify when and how specific vascular access devices (VADs) are used. Understand the risks posed by VADs and implement procedures to reduce infections. Assess healthcare personnel performance in relation to preventing infections when using VADs. LTC facilities are host to some common populations, delineated by their use of specific types of medical devices that pose infection risk and/or their cognitive abilities. Topic 1: General and Indwelling Medical Devices Many residents in LTC facilities require ongoing medical care that involves the use of some common devices. General medical devices used by healthcare personnel during routine checkups, diagnostic procedures, and daily hygiene activities may result in infection spread, as may the use of indwelling medical devices. General Medical Devices, Including Ventilators General medical devices are commonly used in LTC settings. These are not single-use devices. This means that they will be used with multiple residents, leading to the possibility that the surfaces of such devices could cause transmission of pathogens and subsequent infection of residents. These devices may, depending on their use and the facility, come in contact with skin (intact and/or non-intact) and/or mucous membranes. Examples of these items include but are not limited to: Stethoscopes. Blood pressure cuffs. Wheelchairs and crutches. Laryngoscopes.  Transfer lifts. Oxygen concentrators. Commode and shower chairs. As with all other medical devices, proper care must be taken to prevent healthcare-associated infections as a result of the use of these devices. Ventilators Some LTC facilities may care for residents who have a tracheostomy and are chronically dependent upon a mechanical ventilator for respiratory care assistance. Ventilator dependence increases the risk for infections such as pneumonia and other medical complications. Residents on ventilators may require additional assistance from healthcare personnel, including for oral hygiene, operating bed controls (elevating the resident’s head, for example), and maintaining the ventilator circuits. The IP should ensure that evidence-based strategies to prevent ventilator-associated pneumonia (VAP) are incorporated into facility policy and practiced at the bedside. Indwelling Medical Devices Indwelling medical devices serve to preserve or replace failing “natural parts” such as hips, knees, and valves or to facilitate certain bodily functions. Examples include permanent or long-term implanted devices such as artificial hips, knees, pacemakers, and heart valves. Temporary or shorter-term indwelling devices also may be used. Examples of these include urinary catheters and vascular access devices. (A separate discussion covers the topic of vascular access devices.) Infections caused by devices implanted in individuals result from the interaction of factors associated with the type of device being placed, the organism involved, and the host. In general, infections associated with implantable devices commence in one of three usually distinct manners: Introduction of the organism at the time of insertion (e.g., indwelling catheters) or surgical implantation (e.g., joint replacement) Contiguous spread of postoperative wound infection Hematogenous seeding of the device from transient bacteremia or fungemia after the device has been inserted Many indwelling medical devices are common among residents in LTC facilities, as they can greatly improve the quality of life for individuals who use them. However, each device has its own risk of infection, some of which may lead to or contribute to the potential death of the resident. As evidenced by the manners in which infections associated with these devices may commence, much of the infection risk occurs at the time the devices are inserted/implanted, during maintenance/replacement, or during recovery. Key Point With regard to indwelling medical devices, there are a few key points for IPs in LTC facilities to remember. Many of the more “permanent” devices, such as pacemakers and joint replacements, are implanted outside of the LTC facility. The key IPC consideration in such cases is troubleshooting infections that may be associated with the devices. These infections may appear long after the devices were implanted, especially following additional invasive procedures or other infections. However, many other indwelling devices exist that may be implanted and removed by nursing staff in the long-term care facility. IP focus for these types of devices must span the entire procedural life of the device, from pre-insertion through device removal and resident recovery. Topic 2: Vascular Access Devices and Dialysis Vascular access devices (VADs) are commonly used in LTC facilities. They come in many forms. Different types of VADs, including those used for dialysis, pose specific infection risks and must be cared for carefully to prevent infection. Introduction to Vascular Access Devices Obtaining and retaining reliable vascular access has become one of the most essential concerns of modern healthcare. It is crucial for infusion therapy, which is the administration of fluids and medications from a catheter into a vein. Increasingly, infusion therapy is administered in LTC facilities as opposed to acute care hospital settings. Unfortunately, vascular access is associated with substantial and generally under-appreciated potential for producing healthcare- associated infections, particularly bloodstream infections originating from contamination of the device used for vascular access, and other injuries arising from medical care. Bloodstream infections (BSIs) are infections in the vascular system, including bacteremia, fungemia, and viremia. The possibility of infection is true across all healthcare settings and is especially important in LTC settings, as the resident population tends to be more susceptible to infections. A vascular access device (VAD) is any device used to access the vascular system for hemodynamic monitoring, medication administration, infusions, blood sampling, or dialysis. VADs may be placed for a short term (usually less than three weeks) or a long term (weeks to months), and they may be placed in multiple locations in a patient or resident. Every type of VAD carries some risk of causing BSIs, although the risk level varies depending on the VAD type and insertion location. Note that infections associated with VAD may range from local to systemic. Employers must perform a hazard assessment to determine when and what personal protective equipment (PPE) is necessary when performing a procedure that may result in exposure to blood or other potentially infectious materials. This applies to work with catheters and dialysis, discussed elsewhere. Recommendations vary as to what levels of PPE are necessary for a given procedure, depending on the nature of the procedure and the body producing the recommendation; however, standard precautions must be followed at a minimum. More in-depth explorations of PPE and standard procedures are included elsewhere in this learning system. We will now examine a few types of VADs to better understand the most common forms encountered in the LTC: Central venous catheters Peripheral vascular devices Midline catheters Peripherally inserted central catheter (PICC) lines Tunneled catheters Implanted ports Central Venous Catheters (CVCs) A central venous catheter (CVC), also known as a central line (c-line), is a catheter typically inserted into the neck, chest, groin, or arm that terminates close to the heart or in one of the great vessels. Some of the other VADs discussed in this topic are kinds of CVCs (for example, PICC lines, tunneled catheters, and implanted ports). The CVC is used to quickly deliver fluids, blood, or medications to a patient and can also be used to conduct certain medical tests. A CVC can be left in place for weeks or months, and medication can be administered through them multiple times a day (depending on the illness and treatment regimen). Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable. The IP must carefully monitor the resident for signs of CLABSI. Peripheral Vascular Devices Peripheral vascular cannulation (insertion of a cannula, or a small tube, into a body cavity, duct, or vessel) is used for drawing blood samples and administering medication, among other things. In long- term care, peripheral vascular devices are inserted into veins (for example, on the back of a resident’s hand). Peripheral catheters are typically three to six centimeters in length, inserted into the peripheral vessels (both arteries and veins) of the upper extremities, and used for short-term infusion therapy. Vein use for peripheral IV therapy is more common in LTC facilities. Longer peripheral catheters may be used when deeper blood vessels must be accessed, although they require specialized imagery during placement and specialized training and competencies. Peripheral VADs are recommended when infusion therapy is 14 days or less in duration. It is believed that the risk of vascular access device-associated BSI is low with peripheral catheters. However, the risk still exists, along with the potential for other complications. Midline Catheters Midline catheters are longer than other peripheral catheters and require the use of specialized imaging techniques (such as ultrasound) to assist with placement. In addition, healthcare personnel who are installing a midline catheter must wear sterile gloves and gowns and a face mask during the procedure. Midline catheters are designed to remain in place up to 30 days, depending on the manufacturer. PICC Lines Peripherally inserted central catheter (PICC) lines are long-term vascular access devices intended for infusion therapy lasting weeks, months, or possibly even years. The catheter lengths are usually 45 centimeters or longer. The catheter is inserted into a peripheral vein of the upper extremities and advanced until the tip lies in the lower one-third of the superior vena cava or cavoatrial junction. Because of tip location, PICC lines are considered central vascular access devices (CVADs) and can accommodate irritant and vesicant infusion therapy, including total parenteral nutrition and antineoplastic chemotherapy infusions. To confirm placement of the PICC line, an ultrasound or chest x-ray may be used. (However, it is not always the case that an ultrasound will be available—for example, if PICC insertion is done by a contracted infusion service nurse.) Tunneled Catheters A tunneled catheter is surgically inserted into a vein in the chest or neck and then passed under the skin. One end of the catheter comes out through the skin so medicines can be given right into the catheter. There are two kinds of tunneled catheter: cuffed and non-cuffed. The cuffed variety can be used for temporary access beyond three weeks. The non-cuffed variety is for emergencies and can be used for up to three weeks. Implanted Ports Implanted ports are surgically inserted and tunneled but have no visible catheter at an exit site. Usual placement involves the chest and subclavian or internal jugular veins, but they can also be placed in the upper arm similar to a PICC and in the abdomen or femoral area with the catheter tip in the inferior vena cava at the level of the diaphragm. Implanted ports have the lowest reported rates of vascular access device-associated bloodstream infections (VADA BSIs). Basic Approaches to Preventing Infections with VAD Use Bloodstream infections associated with VADs arise from several sources: infection associated with the VAD itself (due to contamination of the device), contamination of the fluid administered through the device, remote sources of infection, and other risk factors that are modifiable. Methods of preventing infections associated with these devices can be broken down into three general categories, based on when they apply (before, at, and after insertion). These concepts will be discussed in more detail later on, but at a high level, they are as follows. Before insertion: Specialized education, training, and competencies. This refers specifically to the insertion, care, and maintenance of VADs, including indications for use, appropriate insertion and maintenance practices, the risk of BSIs, and general infection prevention strategies for VADA BSIs. Evidence-based list of VAD indications. Even with the education component described above, recommendations still include the existence of an evidence-based list of indications for use of VADs. This should be included in established organizational policies, procedures, and practice guidelines in accordance with the manufacturer instructions for use. At insertion: Adherence to infection prevention practices. The existence of infection prevention practices and principles in LTC facilities is crucial. However, the presence of the practices and principles is not enough. The policies must be followed to be effective. While best practices recommend that unnecessary personnel be limited during insertion, recommendations state that a second trained healthcare worker with the power to stop the procedure should be present at all insertions of VADs. Hand hygiene. Appropriate hand hygiene procedures must always precede the insertion of a VAD, and they should also precede subsequent handling of the device and its administration set, dressing changes, and replacement or repair of catheters. Use of sterile gloves is recommended for placement of all VAD types except for peripheral IV catheters, which may use disposable nonsterile gloves if the healthcare worker makes sure to not touch the insertion site again after cleaning the skin in preparation for insertion. Site selection. Assessing appropriate sites can help reduce the risk of BSIs. This includes avoiding the use of femoral sites unless necessary for other reasons, as the use of femoral veins has been shown to increase the risk of VADA BSIs. Note that studies have shown certain insertion locations to be less likely to result in BSIs, although due to other factors, they may have similar overall risks to the patient, meaning that there is no true “optimal” site for insertion if all potential complications are of equal concern. Catheter carts or all-inclusive kits. The use of a standardized CVAD cart or an all-inclusive kit encourages a consistent, standardized approach to CVAD insertion. Essential supplies such as catheters, guidewires, sterile gloves, drapes, personal protective equipment, and needles are readily available, minimizing interruptions and ensuring maintenance of a sterile field. Ultrasound guidance. Use of ultrasound to aid in the placement of devices is recommended for certain types of VAD placement, as is described earlier. This can help reduce the risk of infection as well as other noninfectious complications while reducing the number of attempts needed for successful placement. Ultrasound guidance should be used by only fully trained healthcare workers. Maximum sterile barrier precautions. Use of sterile gloves, a long-sleeve sterile surgical gown, mask, cap, and large, sterile full body drape has been shown to significantly reduce the incidence of BSI during CVAD placement. Recommendations differ for other types of VAD placement. For example, for peripheral arterial cannulation, some sources recommend maximum barrier precautions and others recommend standard barrier precautions. Skin preparation. Recommendations also vary for skin preparation, with sources alternatively recommending the use of 70% alcohol, tincture of iodine, >0.5% chlorhexidine, or other  alternatives depending on the type of insertion and whether there are any contraindications for use. However, regardless of the antiseptic used, it is recommended that the antiseptic agent be allowed to dry completely prior to insertion. After insertion: Staffing. A proper nurse-to-patient ratio helps reduce the incidence of BSIs, according to several studies. Catheter hub disinfection. Recommendations state that catheter hubs should be disinfected prior to every access, as colonization of catheter hubs is thought to cause 50% of post-insertion VADA BSIs. However, studies are ongoing as to the optimal scrub time, which has led to difficulty in establishing a standardized best- practice recommendation. Currently, recommendations state that scrubbing should be done for no less than five seconds. Remove non-essential catheters. As risk of VADA BSI exists whenever VADs are in place, it is recommended that reviews be undertaken daily as to whether each line currently in place is necessary. Those that are unnecessary should be removed promptly. This decision may be based on the existence of mechanical complications, the cessation of use of the catheter, or other criteria. However, they should not be removed based solely on dwell time. Vascular access device dressings. Regular changing of dressings (every two days for sterile gauze, every seven days for sterile transparent, semipermeable dressings, or sooner if either type is no longer dry or intact) can help reduce VADA BSIs. Skin preparation with use of >0.5% chlorhexidine with alcohol is recommended, as long as such preparation is compatible with the catheter material for dressing changes. As with some recommendations for during insertion, use of barrier precautions varies. Administration sets and add-on devices. Minimizing the use of add-on devices such as extension sets, needleless connectors, and secondary sets helps reduce the potential for secondary infections. Add-on devices used with systems for continuous infusions (closed systems) do not need to be changed as often as those used in systems with intermittent infusions (open systems). Skin decolonization with chlorhexidine. Evidence supports the use of chlorhexidine bathing in all patients with a VAD. Chlorhexidine is available in multiple forms, so it is important to follow the manufacturer’s instructions for use.  Topical antimicrobial ointments. Generally speaking, topical ointments are not recommended for use with most VADs, as they may promote fungal infections and antimicrobial resistance. However, in certain situations (related to hemodialysis, discussed later), their use may be recommended. VADA BSI surveillance. Depending on the location of the facility, VADA BSI surveillance may be required under state laws. Where it is not legally required, it is still a recommended practice. Surveillance processes can be enhanced through the use of electronic healthcare software, eliminating time spent on manual tracking and auditing procedures. Dialysis Dialysis—the mechanical removal of excess fluid, electrolytes, metabolic waste, and toxins that would normally be cleared by the kidneys—has been the foundation of and initial choice for treating end-stage renal disease (ESRD). The process uses osmosis, diffusion, and ultrafiltration to reduce the body’s metabolic waste. Dialysis cannot cure kidney failure; lifelong treatment is needed to maintain normal fluid and electrolyte balance. There are two main types of dialysis:  Hemodialysis (HD), which achieves the removal of fluid, electrolytes, waste, and toxins by passing a patient’s blood through a hemodialyzer. This usually requires patients to receive treatment for two to four hours three times per week. Peritoneal dialysis (PD), which achieves the same outcome by diffusion through the peritoneal membrane. This may take several different forms and may require the continuous or intermittent presence of dialysate in the abdominal cavity. Infection, especially BSI, is a major cause of mortality among hemodialysis patients, second only to cardiovascular disease. IPs working in LTC facilities need to have a basic understanding of dialysis in order to develop policies and procedures that protect the LTC’s susceptible population from infection. Residents with ESRD are at greater infection risk due to the following factors: Short- and long-term vascular access resulting in endogenous bacteria potentially invading the bloodstream Multiple, frequent encounters with the healthcare environment, such as the hospital or dialysis center, that result in increased exposure to multi-drug-resistant organisms Frequent exposure to other patients and healthcare personnel that may result in person-to-person infectious agent transmission  Exogenous pathogen exposure from contaminated sources (e.g., hands of healthcare personnel, equipment, or supplies) Co-morbidities (e.g., diabetes) Residents with chronic kidney disease and their families should be educated on the importance of infection prevention strategies, including maintaining the hemodialysis catheter, hand hygiene, and vaccination. Regulations regarding dialysis are very detailed and prescriptive. Attention must be paid to these regulations, including awareness of any changes, in order to provide residents with proper care. In addition to the aforementioned education of residents and their families, risk of infection and adverse reactions for those on dialysis can be reduced by: Strict adherence to aseptic techniques during all dialysis procedures. Strict adherence to procedures for the use, disinfection, and maintenance of equipment. Knowledgeable, well-trained staff that understand the implications of deviating from established procedures. Careful monitoring of all procedures in which bacterial or chemical contamination can occur.  Routine monitoring and follow-up of patients undergoing dialysis, including an active infection surveillance and prevention program. Many infection risks associated with dialysis are the same as those detailed in the discussion of VADs. One difference is the use of antibiotic ointments. A povidone-iodine ointment has been shown to decrease the incidence of subclavian-associated sepsis in dialysis. Recommendations also provide for the use of this ointment at the catheter exit site if the ointment does not interact with the material of the catheter. Temporary and Short-Term Dialysis Temporary dialysis employs the use of CVCs and is indicated when there is an emergent dialysis treatment need or when waiting for the permanent dialysis vascular access port to heal. Infection risk varies based on a multitude of factors, including: Type of device. Location of device. Method and placement technique. Infection prevention practices (including maintenance and access techniques). Recommended strategies for infection prevention include hand hygiene and aseptic techniques, maximum sterile barrier precautions, skin preparations, and catheter site dressing regimens. Short-term dialysis requires the use of a temporary dialysis access catheter in the jugular, subclavian, or femoral veins. Infection risks associated with this will be similar to risks posed by other catheters placed for short-term use, described elsewhere. Long-Term Dialysis Long-term dialysis requires an arteriovenous (AV) fistula or graft. AV fistulas are generally preferred because they last the longest, have the best performance, and are less prone to infection and clotting. To create a fistula, an artery and a vein are artificially joined to allow arterial blood to flow through the vein, which causes the vein to enlarge and the vessel wall to thicken. These take a few months to heal and function properly; temporary dialysis is used in the interim. Care must be taken to keep the fistula site clean and avoid procedures that may increase infection risk or otherwise slow the healing process. Steps and precautions to that end will be included in postoperative directions, following the installation of the fistula. AV grafts are similar to AV fistulas but are used when patients have veins that will not develop into a suitable fistula. These may be biologic, semibiologic, or prosthetic and function to join an artery and a vein (as is done with an AV fistula). The graft is surgically implanted under the skin in the arm in an outpatient procedure. Recovery and maturation of the graft is typically faster than with an AV fistula (three to six weeks). As mentioned before, these generally do not last as long as AV fistulas, and complications resulting from infection may be more severe due to risk of disintegration of graft materials and subsequent bleeding. Topic 3: Other Special Populations and Socialization Considerations Memory support for residents with cognitive impairment such as dementia may be needed in any LTC facility, regardless of specialization, and may overlap with other special populations that require specific care with regard to infection prevention. Memory Support and Cognitive Impairment Reduced cognition or altered mental status can lead to several detrimental outcomes with regard to infections, for example, difficulty detecting infection symptoms leading to longer infection progression before precaution and treatment procedures can begin. This may be a result of an incomplete understanding of the mental status of the resident on the part of a member of the IDT; it may also arise from the inability of the resident to verbalize how they are feeling. This can also increase the infection risk for both the resident with reduced cognition and those around them. The risk posed to the resident with reduced cognition arises due to the resident potentially having decreased ability to care for their own hygiene, which may lead to increased colonization risk, which may lead to infection. Risk to others with reduced cognition arises from the resident struggling to comply with processes designed to prevent the spread of communicable diseases, such as hand and respiratory hygiene procedures. Key Point It is important to note that reduced mental or cognitive function is not always a long-term issue with residents, nor is it always independent from infection. As described in an article in Clinical Infectious Diseases by Kevin P. High et al., infections in elderly individuals may present in uncommon or unexpected ways, including as a change in mental or cognitive function as a symptom of an underlying infection. As such, it is crucial that the mental capacity of older individuals be monitored and assessed before, during, and following recovery from infections. Hospice, Palliative, and Respite Care Hospice and palliative care both focus on managing the symptoms of an illness, with an emphasis on controlling the discomfort and pain that a patient experiences while incorporating the spiritual, cultural, and religious needs of the patient and family or support system. Respite care is generally used when the patient’s caregivers or family become fatigued and need a break. If the patient resides in a personal residence, the patient may be temporarily transferred to a facility for up to five days and then transferred back home. By that time, the family is usually more rested and better prepared to meet the patient’s care needs. With regard to infection risks, it is the variation in the hospice care setting that presents the most significant challenge. The setting in which hospice care is provided affects the ability of the healthcare personnel (HCP) or caregiver to adapt infection prevention measures to meet the expressed desires of the patient; certain settings may require adaptation of infection prevention measures. It is important that the patient’s desires and goals be considered so that they maintain a desired quality of life. Care settings can include the patient’s personal home, a hospital, an assisted living facility, a long-term care facility, a group boarding home, a freestanding hospice facility, or a family member’s home, among others. The patient may transition back and forth between facilities. Any potential settings should be assessed to determine what resources and infrastructures are available to provide care for the patient. The assessment data should be used to perform a risk assessment with the patient and family to determine what fits with the patient’s desires and goals. Developing a hospice or palliative plan for LTC facilities may present challenges in meeting the patient’s preferences. Every attempt should be made to incorporate the patient’s preferences in their plan of care, regardless of the setting. Although the patient may understand and accept the risk, the guiding principle should be that it does not cause harm or potential harm to other patients, caregivers, and HCP. Regulations still must be followed, and these regulations may need to be explained to the patient and their family. Key Point Device use in hospice and palliative care patients may involve central lines, feeding tubes, noninvasive respiratory aids, urinary catheterization, etc. Before a device is placed in a hospice/palliative care patient, the device and its purpose, care, benefits, risks, potential complications, and projected duration of use need to be openly discussed with the patient and incorporated into the plan of care if the patient agrees to the device. Some devices may be used for comfort measures in this patient population (e.g., urinary catheter so the patient can sleep through the night or conserve energy; central line for pain medications and/or other medications that reduce symptoms; antibiotics) even though they may pose a risk to the patient. Care and maintenance should follow the established standard of care for the device. If the patient requests to not follow these standards, the healthcare team should seek alternative methods of device care that meet the patient’s desires while providing optimal mitigation of infection and or adverse events. Impact of and Need for Social Gatherings As evidenced during the SARS-CoV-2 pandemic, prolonged isolation of residents in LTC facilities leads to increased anxiety. SARS-CoV-2 is but one example, but it illustrates why any precautions or methods implemented in response to infection outbreaks must be undertaken with clear consideration of the associated psychosocial consequences compared to the potential infection prevention benefits. Doing so helps ensure that the LTC facility is following Centers for Medicare & Medicaid Services (CMS) requirements for the provision of a “home-like environment” and “person-centered care,” which necessitates consideration being given to each resident’s socialization activities and quality of life. LTC facilities are tasked with providing a safe environment for all residents, free from infections and exposure to communicable diseases, while providing residents the opportunity to engage in social activities for their psychosocial well-being. Many of the supporting activities that are implemented in LTC facilities are discussed in more detail in the discussion of ancillary services, which pose additional infection risks. Social/Communal Gatherings Elderly individuals living in LTC facilities may be at a higher risk of infection due to the communal nature of these facilities. Sharing entertainment, eating, and exercise areas increases the ease of transmission and outbreaks associated with contaminated facility water or food, healthcare personnel cross-contamination, or visitor exposure. The increase in ease of transmission may arise from many factors, including close proximity of residents, poorly ventilated spaces, the absence of supplies and/or signage with instruction to encourage individuals to comply with hand hygiene and respiratory hygiene protocols. To help reduce the effects of these, residents symptomatic with infection should defer communal activities until symptoms resolve, and staff and residents should be educated on the increased risk of transmission and strategies to mitigate the risk. Thus, LTC facilities present a unique challenge for IPs. The high multi- drug-resistant organism (MDRO) colonization rates and the frequency of risk factors among the residents (as well as mobile residents) may contribute to healthcare-associated infections and outbreaks. Specific prevention guidelines and recommendations for LTC facilities are available to help reduce the risk of infections including MDROs and outbreaks. Section D: Regulating Bodies After completing this section, learners will be able to: Understand the different layers of regulations that govern LTC facilities. Distinguish between laws/regulations and guidelines. Identify United States regulatory bodies and understand how their directives apply to LTC facilities. Understand the role of the World Health Organization in international healthcare guidance. Regulations may be issued by multiple different agencies and governmental bodies at several different levels. Additionally, guidance and recommendations that are not enforceable as regulations are available from multiple sources. Topic 1: Levels of Regulating Bodies in the U.S. and Other Considerations In the United States, regulations may be issued by a variety of bodies that exist at the federal, state, and local levels. Understanding which regulations to follow, and which ones apply to the IP’s specific LTC facility, is crucial. Laws and Regulations versus Guidelines Terminology in the area of laws, regulations, and guidelines is important. Laws and regulations must be followed, or severe penalties may be imposed. Laws are passed by the legislature of the federal or state entity (or by the lawmaking body of a city—usually, but not always, the city council). Laws may directly set out requirements that must be followed by a given person or facility, or they provide authority to a regulatory agency. For example, the Centers for Medicare & Medicaid Services (CMS) requires LTC facilities to establish and maintain IPC programs, including antibiotic stewardship and at least one infection preventionist. Regulations and laws may arise from all three levels of government; regulatory agencies and lawmaking bodies are not exclusively found at one level or another. Regulatory agencies cannot issue regulations that override statutory law that was passed by an act of legislation. However, when agencies issue regulations, the regulations carry the weight of law and compliance with them is mandatory. Generally speaking, regulations change faster than laws, due to political changes in the executive branches and the typical speed at which regulations are passed compared to laws. Guidelines are framed as recommendations, and they are written to provide practice guidelines. These typically are based on expert consensus and the most current, best scientific evidence. Best practice is to follow guidelines, although they are not enforceable via legal penalties. The Centers for Disease Control and Prevention (CDC) publishes extensive guidelines on a number of healthcare- related topics, including infection prevention and control—for example, guidelines on cleaning and disinfecting facilities, LTC facility vaccine recommendations, use of personal protective equipment (PPE), and antimicrobial stewardship. Key Point As evidenced by the above concepts, laws and regulations form a complex web that is continually changing and manifests differently depending on the specific location of a facility (including differences between state location and facilities outside of the U.S.). Memorizing the details of the ever-changing environment is likely impossible. However, the following information is helpful to know: Which agencies regulate your facility The reportable illness list for your facility Local health department officials Outbreak reporting requirements How to get listings and information from health departments Federal, State, and Local Regulations Federal governmental agencies can be placed organizationally in terms of their relationship to the three branches of the U.S. government. That is, agencies fit as extensions of the legislative, executive, or judicial branches of the government. Most federal agencies that impact LTC facilities, especially from an IPC perspective, stem from the executive branch. Through these agencies, such as the CMS and others, the federal government regulates nursing homes and skilled nursing facilities. State and local regulations comprise the lower authority levels from which regulations may arise. States have multiple departments that parallel the functions of the federal agencies—that is, jurisdictions related to health, education, welfare, environment, agriculture, and so forth. The organizational structures