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Infection Prevention and Control Audits: Start with Hand Hygiene

Nursing homes can have the most beautiful policies and procedures for infection prevention and control in the world, but if staff aren’t following through on them, they are a waste of paper, notes Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and faculty member at the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA.


“So monitoring and auditing infection prevention processes in the facility is a critical component of quality care,” says Burdsall. “Unfortunately, the focus on infection prevention has not always been well-supported because infection surveillance, monitoring whether proper supplies are available and used correctly, and watching whether staff are performing hand hygiene and correctly using personal protective equipment all take time, which means the effort costs money.”


In the long run, however, dedicating more hours to infection prevention and control in order to have an actively functioning program can save time, money, reputation, and lives, says Burdsall. “Infection prevention and control is not just a regulatory requirement. You will have fewer residents and staff who get infections, fewer hospitalizations, fewer medications, fewer disgruntled residents, and fewer call-ins if you have a functioning infection prevention and control program,” she explains. “So it’s time to give infection prevention the importance that it needs.”


Directors of nursing services (DNSs) should monitor and audit common concerns cited under F880 (infection prevention and control), starting with hand hygiene. “I’ve participated in several national infection control programs, and the most consistent problem is a lack of appropriate hand hygiene,” says Burdsall. (See the top five reasons for F880 citations in the box at the end of this article.)


Make alcohol-based hand rubs No. 1 for hand hygiene


Many providers still don’t understand that alcohol-based hand rubs (ABHRs), not soap and water, are the Centers for Disease Control and Prevention’s (CDC) preferred method of hand hygiene, says Burdsall. “There is a misconception in long-term care that you can’t use alcohol-based hand sanitizer. However, the science, the CDC, and the interpretive guidance from the Centers for Medicare & Medicaid Services (CMS) all say that, with two exceptions, alcohol-based hand rub is the preferred method of hand hygiene.”


The Infection Control Policies and Procedures section of F880 in Appendix PP of the State Operations Manual states that providers must develop and implement written policies and procedures for infection prevention and control, and one of the minimum requirements is to include “how to use standard precautions and how and when to use transmission-based precautions (i.e., contact precautions, droplet precautions, airborne isolation precautions).”


The first listed precaution under that requirement is: “Hand hygiene (HH) (e.g., hand washing and/or ABHR): consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled (e.g., blood, body fluids), or after caring for a resident with known or suspected Clostridium (C.) difficile or norovirus infection during an outbreak, or if infection rates of C. difficile infection (CDI) are high; in these circumstances, soap and water should be used[.] NOTE: According to the CDC, strict adherence to glove use is the most effective means of preventing hand contamination with C. difficile spores as spores are not killed by ABHR and may be difficult to remove even with thorough hand washing. For further information on appropriate hand hygiene practices see the following CDC website: http://www.cdc.gov/handhygiene/providers/index.html.”


So DNSs should “review policies and procedures very carefully to ensure that nothing in those policies and procedures would limit the use of alcohol-based hand rubs,” says Burdsall.


Point-of-care access matters


“In addition, hand hygiene needs to be available at the point of care,” she notes. F880 in Appendix PP discusses providing “conveniently-located dispensers of ABHR and supplies for hand washing where sinks are available” as part of implementing policies and procedures for respiratory hygiene/cough etiquette.


However, providers do have to address potential resident access concerns. §483.90(a)(4) of the CFR contains the following life-safety caution: “A long-term care facility may install alcohol-based hand rub (ABHR) dispensers in its facility if the dispensers are installed in a manner that adequately protects against inappropriate access.”


“The evidence in the literature shows that wall-mounted ABHR can be a risk to pediatric and psychiatric populations, but currently there is no evidence that they pose a risk to persons with dementia,” says Burdsall. “If DNSs who are concerned about ABHR have wall-mounted soap dispensers, which look just like wall-mounted dispensers for alcohol-based hand rubs, I’d suggest doing an audit to see if residents with dementia have ever accessed the wall-mounted soap dispensers because the wall-mounted ABHR is a critical piece of allowing access to hand-sanitizing at point of care.”


However, if there are concerns, “the CDC allows—and the literature supports—the use of pocket-sized alcohol-based hand rubs or alcohol-based handwipes as well,” says Burdsall.


Another common issue is personal protective equipment (PPE). “In addition to having alcohol-based hand rub at point of care, DNSs need to make sure staff have appropriate PPE at point of care,” says Burdsall. “Staff also need to be competencied on both how to perform hand hygiene and how to put on PPE.”


Top 5 reasons for F880 citations


• Hand Hygiene

Failure to wash hands or change gloves during personal cares or during treatments

Failure to wash hands during medication administration

Resident(s) not offered hand washing (before meals, after personal cares)


• Outbreak management

Line lists* inaccurate or incomplete

During an outbreak, did not restrict staff movement between units

Did not identify onset of outbreak in a timely manner


• Transmission based precautions & PPE

Not wearing personal protective equipment or immediately disposing

Resident not in transmission-based precautions when should have been


• Surveillance

Did not calculate rates of infection or analyze trends

Line list* did not contain all residents with potential infection


• Cleaning & Disinfection

Did not place barrier between surface and equipment

Glucometer not disinfected

Contamination of medications during med pass


Source: Slide set for Webinar 5, “Frequent Citations: What Are We Missing?,” in the six-part “Infection Preventionist” webinar series from the Lake Superior Quality Innovation Network.


* A line listing or line list is a surveillance and outbreak management data collection tool that identifies potential, probable, and/or confirmed cases of infection by important variables, such as the onset date, signs and symptoms, lab results, etc. See a sample Excel-based line list tool for infection and antibiotic use tracking from the Minnesota Department of Public Health here.


According to the Infection Surveillance section of the Infection Prevention, Control, and Immunizations critical element pathway (form CMS-20054), surveyors will assess whether “[t]he plan uses evidence-based surveillance criteria (e.g., CDC NHSN Long-Term Care or revised McGeer Criteria) to define infections and the use of a data collection tool.”


Similarly, the Antibiotic Stewardship section of the pathway requires surveyors to assess whether the facility’s antibiotic stewardship program includes “Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g., SBAR tool for urinary tract infection (UTI) assessment, Loeb minimum criteria for initiation of antibiotics)[.]”


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