Infection control in long-term care facilities: the hospital-based practitioner's role.

Abstract

Over a lifetime, the risk of entering a nursing home and spending a long time there is substantial. Kemper and Murtaugh have estimated that of the approximately 2.2 million persons who turned 65 in 1990, more than 900,000 (43%) will enter a nursing home at least once before they die.1 They report that almost 33% of all persons who reached 65 years of age in 1990 will spend at least three months in a nursing home during their lifetimes; 24% at least a year; and 9% at least five years. The risk factors that predispose an elderly person living in a long-term care facility to infection are numerous. In addition to the immune system function changes that occur with aging,2 elderly residents of long-term care facilities usually have multiple underlying medical conditions that increase the risk of infection, including Alzheimer's disease and other causes of dementia, organic heart disease, malignancy, peripheral vascular disease, diabetes mellitus, and chronic obstructive pulmonary disease. Inappropriate use of antibiotics in long-term care facilities has been documented,3 and the frequent use of sedatives and hypnotics may also contribute to the infection problems seen in these facilities. Atypical presentation of infections, with signs and symptoms varying from those of a younger person, is generally acknowledged4 and may lead to delays in diagnosis and treatment. Environmental and facility-related factors vary widely from facility to facility, just as they do in the acute care setting, and they probably play a larger role in predisposing elderly residents in long-term care facilities to infection than for patients in the acute care setting. The microbial flora of residents in long-term care facilities is different from those living in the community, and within the long-term care facility it differs between residents who are alert and ambulatory and those who are bed bound.4 Unusual or resistant microorganisms may be endemic but unrecognized until a major outbreak occurs.5,6 The physical plant of many long-term care facilities may be a factor in infections; many residents frequently live in a relatively confined, small area where there are few private rooms and perhaps no rooms appropriate for isolation. Many long-term care facilities experience rapid turnover of personnel, and resident care personnel frequently have less training than those in the acute care setting. In addition, long-term care facility personnel are now caring for residents who are much sicker and require more complex care than in the past, due to the current system of hospital reimbursement based on diagnosis-related groups (DRGs).7 The Medicare prospective payment system has decreased the length of inpatient hospitalization days as an incentive to reduce the length of stay, and patients are being discharged to long-term care facilities with more complicated plans of care. 8-10 Moreover, the repeated transfers or ping-ponging of elderly patients between acute care facilities and long-term care facilities is increasingly evident. Of the patients 65 or more years of age who survive hospitalization, 80% will be discharged to a nursing home and of these, 60% will be readmitted to the hospital at least once in the following 18 months.11 As with acute care facilities, there are many degrees of expertise and sophistication in long-term care infection control. There are some long-term care facilities whose management or owners have seen the value of a well-developed infection control program and are willing to provide the financial support needed