Infection Control among the Elderly in Today's Skilled Nursing Facilities

Based out of Dallas, Texas, and with more than 38 years of experience in the long-term care industry, Ms. Chustz is passionate about geriatric care. Over the years, she has worked as a director of nursing, regional nurse consultant, director of education, senior manager of infection control, and corporate director of education/professional development and infection control. Ms. Chustz’s specific passions include infection control, skin and wound care, teaching and coaching, and the professional development of others. She has participated at conventions and conferences across multiple states through state healthcare associations as a speaker on a variety of topics. Bonnie Chustz has additionally participated on the American Healthcare Association’s Workforce Committee, addressing workforce needs in the long-term care industry. She holds current certifications in infection prevention and control and long-term care infection prevention and control.

To begin, let’s review the basics of skilled nursing facilities (SNF). These are the primary locations of residence for the elderly population, who are no longer able to independently care for themselves in their home environment. Residents are often admitted to SNF following a hospitalization for an illness, an injury, or a decline in function, and they may reside in the facility for a short time of recovery while others remain indefinitely. Most SNFs are composed of semi-private rooms, so once admitted, a resident will likely share a room with another resident; one may compare this to a college dorm in its similarity. SNFs have shared dining spaces and common areas for activities and events.

The majority of SNF residents are elderly people with aging bodies and systems, including their immune systems. Infections are not caused by aging, but as the body ages, all systems fail to function as well as they once did. Residents are admitted with a list of diagnoses and an accompanying list of medications they must regularly take as prescribed. The effects of disease processes, coupled with the effects of medications and the effects of aging, can predispose residents to increased infection susceptibility.

Because of the dorm-like living environment, aging effects, and varied diseases and illnesses present when a person enters a skilled nursing facility, residents who live in SNFs are at a greater risk of acquiring transmissible infections than elderly persons living in their own homes. In the facility, infection prevention and control practices must be married to homelike living as well as healthcare facility infection control practices. What does this mean? Unlike in a hospital, residents in SNFs are encouraged to bring personal items and decorations from home to create their own homelike space. Because this is a residence and community, residents are encouraged not to stay in their rooms but to engage in activities, exercise, dining, and socialization outside of their rooms. Think college dorm life again. The intent of a skilled nursing facility is to provide healthcare that meets medical, physical, social, spiritual, and emotional needs for each resident in order to provide the best quality of life possible at this point in their life’s continuum. Resident rooms are not like hospital rooms but are geared toward personalization.

Federal regulations for skilled nursing facilities created by the Centers for Medicare and Medicaid Services (CMS) address isolation to control the spread of infection this way: “isolation should be the least restrictive possible for the resident under the circumstances.” Skilled nursing facility staff realize that keeping a resident in isolation for an extended period of time to prevent the spread of an infection greatly reduces the resident’s quality of life and can be detrimental to their overall health and wellbeing. To combat infection risks, SNFs combine knowledge of the environment, resident population, and medical histories to understand unique infection prevention and control challenges. Microorganisms, specifically bacteria, are ubiquitous. 

Many residents who live in SNFs have been treated for an infection caused by bacteria within the past year. Often, after the acute  infection is resolved, these bacteria remain in or on the body, but not in enough quantity to cause an acute illness. This is called “colonization,” where the bacteria causing the infection and the normal bacteria always in the body coexist somewhat in harmony until the “bad” bacteria find an opportunity to start multiplying and causing symptomatic infection once again.

Unfortunately, just like a dog sheds hair into the environment, bacteria in and on the body shed regardless of whether they are colonized or infected. Bacteria are microscopic, so they cannot be seen by the naked eye, but they are definitely present and can contaminate surfaces the resident or the resident’s body fluids touch. Residents shed bacteria most heavily in their rooms, close to and on their beds. These bacteria can be picked up by others through touch (e.g., touching the resident’s skin, body fluids, or environment around the resident). An analogy of how this happens is to consider the honeybee. The honeybee flies from flower to flower, picking up pollen from one source flower and depositing some of that pollen on other flowers. New flower variations are created through cross-pollinization, which is the spreading of pollen from one flower to another. Similarly, once picked up by a caregiver, bacteria can be transported to other residents or other surfaces through touch. Caregivers, visitors, and residents pick up these bacteria and deposit them wherever they go, which is why hand hygiene remains the single most effective way to stop the spread of infection to others. We must get the pollen (i.e., bacteria) from one resident off of our hands before touching anything or anyone.

To combat this ubiquitous world of bacteria, which can and does cause infections and is even harder to treat, skilled nursing facilities have begun following updated guidance from the Centers for Disease Control and Prevention (CDC) called “Enhanced Barrier Precautions (EBP)”. Following EBP, caregivers put on an isolation gown and gloves when providing close, direct care to residents who are colonized or infected (excluding infections that require isolation). The caregiver removes the gown and gloves and performs hand hygiene before caring for any other resident. These actions greatly reduce the risks of the caregiver becoming a “honey bee” and transferring bacteria from one resident to another in the SNF. Residents receiving EBP care are not confined to their rooms but are free to continue living and enjoying life to the fullest extent possible while residing in the SNF. The use of EBP in addition to cleaning and disinfecting practices throughout the facility significantly reduces the risks of transmitting bacteria from one resident to another and reduces the chances of “catching” an infection from others.

We have learned much from the COVID-19 pandemic about reducing the risks of infection, and in the SNF world, three basic practices stand out and continue to be the norm in today’s modern healthcare world: (1) frequent and appropriate hand hygiene; (2) source control— implementing practices like EBP; and (3) cleaning and disinfecting of the environment.

Looking towards the future, technology will one day improve the quality of infection prevention and control practices in skilled nursing facilities. How? The world of healthcare may not have these answers yet, but we are confident that the medical technology industry is on that path.