Development of nursing home infection control.

Abstract

The demographics of aging America have been well documented. In 1994, one eighth of the total population was over 65, and the most rapidly growing segment of the population is the age group 85 and older.1 The increasing number of elderly in the United States is the major factor leading to the rise in long-term–care residents, the vast majority of whom are over 65 years of age. According to some projections, approximately 40% of persons who turn 65 will spend some time during their life in a nursing home.2 Currently, approximately 1.5 million nursing home residents reside in approximately 17,000 nursing homes or long-term–care facilities (LTCFs) in this country.3 The number of nursing homes is nearly three times the number of acute-care hospitals in the United States. Because LTCFs contain elderly residents with multiple underlying diseases in a closed environment, it is not surprising that nosocomial infections are a common occurrence. In 1985, it was estimated that 1.5 million infections occurred annually in US LTCFs4; that number is probably an underestimate of LTCF nosocomial infections currently. The incidence rate of 5 to 6 infections per 1,000 resident days is roughly comparable to the acute-care hospital nosocomial infection rate.5 Infection control in the LTCF has developed considerably over the last 20 years. LTCF infection control programs are virtually universal in this country. There are a number of studies documenting the incidence or prevalence of nosocomial infections in the LTCF and the descriptive epidemiology of these infections. Many LTCF infectious disease outbreaks have been described and so have some of the risk factors for nosocomial infection. The literature devoted to this topic is increasing rapidly, as seen by this issue of the Journal. These advances in LTCF infection control occurred in spite of a number of inherent disadvantages in the field as compared to hospital infection control. LTCFs have considerably fewer resources and less expertise available for infection control efforts, and, in the vast majority of facilities, the nursing home infection control practitioner has multiple other duties in addition to infection control.6 Laboratory and radiology facilities are less readily available, and the medical record is much briefer than the typical acute-care hospital record, making nursing home research more difficult. Other research obstacles include limited reimbursement for medical care (compared to acute-care facilities), lesser funding due to the “low-tech” focus of long-term care, and the difficulty in obtaining informed consent for studies from a population with a high incidence of dementia. The goal of providing comfort care for the resident at life’s end may conflict with infection control goals.7 LTCF infection control programs face unique challenges and are not well served by assuming that hospital infection control approaches will be uniformly successful in the LTCF. A Canadian consensus group developed surveillance definitions of infection that were specific for the LTCF,8 and LTCF infection control has been advanced by the publication of a number of consensus guidelines. The Society for Healthcare Epidemiology of America (SHEA) published guidelines on antimicrobial use,9 antimicrobial resistance,10 and vancomycin-resistant enterococci (VRE),11 all specific to the LTCF; a guideline on the approach to influenza in the LTCF is being developed. In addition, SHEA and the Association for Professionals in Infection Control and Epidemiology copublished the second edition of a guideline detailing the various components of an infection control program for the specific needs of an LTCF.12