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Risk factors for infection in nursing homes

VOL: 96, ISSUE: 46, PAGE NO: 38

Darryl Pennells, RN, MPH, is community infection control nurse adviser, Worcester Health Authority

As the population ages the number of people being cared for in nursing homes is rising. Traditionally, nursing homes provided long-term care for elderly, frail people with chronic conditions, who required basic nursing care. However, residents today tend to be older, have more complicated medical conditions and require more intensive and invasive care than those cared for 10 years ago. In response to the current move towards community-based care and shorter periods of stay in acute hospitals, many homes now provide other services. These include short-term respite care, day care and admission beds for people experiencing an acute medical crisis, such as a mild-to-moderate cerebral vascular accident, or following trauma, such as a fall.

As the population ages the number of people being cared for in nursing homes is rising. Traditionally, nursing homes provided long-term care for elderly, frail people with chronic conditions, who required basic nursing care. However, residents today tend to be older, have more complicated medical conditions and require more intensive and invasive care than those cared for 10 years ago. In response to the current move towards community-based care and shorter periods of stay in acute hospitals, many homes now provide other services. These include short-term respite care, day care and admission beds for people experiencing an acute medical crisis, such as a mild-to-moderate cerebral vascular accident, or following trauma, such as a fall.

Elderly, debilitated people are recognised as being at increased risk of acquiring infection (Nicolle et al, 1996). It is also recognised that those living in residential settings may be exposed to other factors that increase their susceptibility to infection (Bentley and Cheney, 1990). Acute illness increases a person's risk of acquiring infection and those admitted to a nursing home with an infection may subsequently be a source of infection to others. Despite this, there is little information available in the UK about infection risks or the incidence of infection in nursing homes.

Pilot study
A small pilot study was undertaken in eight randomly selected nursing homes in Worcestershire. The main aim was to identify factors associated with infection risk to which someone living in a nursing home may be exposed as well as determining the incidence of infection in this setting. The study also aimed to highlight the educational needs of staff. The ultimate goal was to test a tool that could be used to identify infection risk and measure infection rates in nursing homes.

Setting up the study
Data was collected by observing standards of practice and the home environment using an audit tool and completing two questionnaires. The infection control audit tool produced by the West Midlands Regional Group of the Infection Control Nurses' Association was used to assess infection control practices and provision within the homes. The audit tool comprises nine standard statements and a list of criteria that need to be met in order to achieve the standard. It can be completed by directly observing the environment and practices.

The first questionnaire was designed to determine the risk factors for infection of each individual resident and to establish the prevalence of infection within each of the homes. The second questionnaire was designed to gather information relating to the home, for example, the number and category of residents, staffing levels and skill mix, facilities and education programmes for all grades of staff.

The total number of available beds in the eight nursing homes included in the study was 336 and of these 305 were occupied (90.7%). Of the 305 residents who took part in the study, the majority (78.3%) were female. The age range was from 57 to 99 years, the mean age being 83.8 years.

Identifying risk factors
All residents were found to have at least one risk factor for infection. The findings are summarised in Table 1. The number and type of infection detected during the study are shown in Table 2.

The risk factors most frequently associated with the presence of infection were age and immobility. None of the results were found to be of statistical significance but it is thought that this could be due to the small numbers involved. However, the total infection rate of 9.5% was found to be similar to those found in studies carried out in nursing homes in America and Canada (Garibaldi et al, 1981; Smith, 1985; Danowski et al, 1991) and in prevalence studies in acute hospital settings in the United Kingdom (Meers et al, 1981; Emmerson et al, 1996).

Antibiotic use
Twenty-two of the residents with infections were being treated with antibiotics. However, in only one of these cases had any microbiological investigations been undertaken. Antimicrobial resistance is an increasing problem worldwide that is exacerbated by the overuse of broad-spectrum antibiotics. The current Department of Health strategy Resistance to Antibiotics and Antimicrobial Agents (DoH, 1998) recommends that improvements are made to ensure accurate information is provided rapidly to prescribers. However, immediate treatment is often required in this vulnerable group and antibiotic therapy is selected on the basis of the most likely causative organism. Staff also reported that transportation of specimens and the communication of results to the homes were also problematic.

In two of the homes an unrecognised outbreak of scabies among residents was discovered by the infection control nurses undertaking the audit. This highlighted the need to raise awareness of the signs and symptoms of this infection among elderly people.

Decontamination of equipment.
The sharing of equipment and facilities poses a potential infection risk. One of the questionnaires highlighted the fact that visiting services, such as chiropody, often shared rooms with other services; space was limited in all of the homes and facilities (for example, provision of a deep sink for cleaning procedures) for the decontamination of equipment was inadequate. A proportion of the equipment used by the visiting services was always brought in and was likely to have been used in other care settings.

It was found that the home staff believed that the equipment provided by visiting professionals was both clean and safe but they had no way of knowing whether this was actually the case.

Education
Continuing education for trained members of staff was found to be provided by attendance at external courses and study sessions arranged in-house led by invited specialist speakers or company representatives.

A three-day infection control liaison nurse course had been available to staff working in nursing homes locally and all of the homes involved in the study had at least one trained nurse on the staff who had attended (see p40).

Attendance at external courses was reported to be difficult on occasions due to staffing levels. Education for untrained carers is predominately provided in-house by trained staff and many now encourage untrained staff to undertake the relevant National Vocational Training course.

Standards of infection control practice
The fact that many nursing homes are converted, older style properties often hinders good infection control practice. Scoring of the audit was undertaken for each of the nine standards. Percentages were determined by dividing the number of criteria met by the total number of criteria for each standard. The audit results are summarised in Table 3.

The infection control audit scores were high and the results were much better than those from audits carried out in nursing homes in the same area five years earlier. The previous audits were carried out before the infection control liaison nurse course had started and before written infection control guidelines were distributed to all homes. It was found, however, that there was still room for improvement in certain areas.

Conclusion
Infection in this vulnerable group carries a high morbidity and mortality. Identification of the risk factors for infection in both the environment and the individual will enable care providers to adopt practices and procedures that can reduce the incidence of infection. Data collection relating to infection rates in this setting will help to demonstrate the efficacy of these interventions. The tool tested in this study can be used to undertake such surveillance.

Following the study, recommendations were made to improve standards. Home owners have been encouraged to provide appropriate facilities, such as a deep sink and a designated cleaning area for the decontamination of equipment. Additional education has also been provided on recognition and management of scabies and the importance of obtaining specimens for microbiological investigation before treatment with antibiotics.

We have decided to evaluate the impact of the training and support programme offered to the homes. The study will now be repeated in an area where specific infection control training has not been provided so comparisons can be made.

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