The nursing home environment presents unique challenges for infection control. Shared rooms, group dining and residents who are free to move around the campus all contribute to risk of spreading germs. But two of the most common hotspots for infections in the skilled nursing setting are intimately related to the residents themselves--incontinence and wounds. Two clinical experts discuss strategies for diligent care delivery to avoid serious infections that can lead to hospitalization or worse.
UTIs: THE HIDDEN RISK
Incontinence is one of the leading causes of urinary tract infections (UTIs). Leah Klusch, RN, BSN, FACHCA, executive director of Alliance Training Center in Alliance, Ohio, says wet undergarments offer the perfect place for an infection to blossom, because they’re moist, warm and dark. Other causes are overuse of antibiotics and catheters that are left in place too long or are not well-maintained.
Another hidden problem is a variance in body temperature. “A lot of elders, especially those in their 80s and 90s, have suppressed body temperatures. Their baseline can be lower than the average adult, sometimes by as much as 2 degrees. If someone with an early UTI has a temperature that isn’t dangerously high to the average clinician, by the time that person gets to 99 degrees, they may be septic.”
Potential embarrassment can sometimes render incontinence a well-kept secret in the skilled nursing facility (SNF). “Some family members bring product in or take mom’s underwear home and wash it,” Klusch says. “The other issue we’re dealing with is that this age group is not open to talking about these private matters.”
Klusch is now working with the Department of Urology at the University of Pennsylvania to establish assessment protocols to be used upon admission or re-admission to the SNF. “You must question residents in a very kind but very persistent way about what their level of continence was before coming into the SNF. Use everyday practical terms. For example, ‘Before you went to the hospital, if you were going to go out with your friends, would you wear a panty pad or any kind of an incontinence product?’ That is so much better than a nurse coming into the room and asking, ‘Are you incontinent?’ For someone to admit that is a tremendous self-exposure.”
WOUND CARE: A DIFFERENT TYPE OF CHALLENGE
“Residents in long-term care are so immunocompromised, that even simple wound infections that aren’t resistant to antibiotics can become problematic,” says Diane Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN, a wound and skin care consultant in York, Pa. “It’s because they have so many comorbidities, and their perfusion isn’t good.”
Ischemic feet and limbs and leg ulcers can prevent systemic antibiotics from getting into the bloodstream, so these wounds are now treated topically. Krasner outlines just some of the new wound care options that are now available and more effective.
- Silver agents have become a favorite because they’re broad-spectrum antimicrobials that deal with all kinds of organisms, such as Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant enterococcus, viruses, bacteria and fungus. Silver dressings have been developed that are sustained-released. Some absorb and others donate moisture.
- Newer forms of iodine have been developed, such as cadexemer iodine, which doesn’t kill new cells.
- Another good alternative is hydroferra blue that is impregnated in a foam dressing. It’s also a broad-spectrum antimicrobial.