Healthcare Acquired Infections in Long Term Care facilities:

Mobile (Portable) Diagnostic Imaging and C. diff. prevention

“Most nursing homes are not paying enough attention to the whole C. diff. issue.”

-Dr. Cliff McDonald, MD, Prevention and Response Branch Chief

CDC Division of Healthcare Quality Promotion

Clostridium difficile: Background and Statistics

Clostridium difficile, or C. diff., is a microorganism commonly found in the intestines of many healthy people as part of the normal intestinal flora.  In conditions often associated with long term care patients, C. diff can quickly multiply to dangerous levels.  In amplified amounts, the microorganism releases enough toxins, normally harmless, to successfully attack the intestinal lining and cause severe diarrhea.  Worse, when a person may have a compromised immune system, the infection can rapidly progress and cause toxic megacolon, sepsis and even death. 

According to the Centers for Disease Control (CDC), 94% of C. diff. infections are associated with receiving some sort of health care.  Of that 94%, the CDC reports that 75% of healthcare acquired C. diff. infections occur in patients discharged into a long-term care (LTC) facility or back into the home following hospitalization.  According to Dr. Cliff McDonald, MD, Prevention and Response Branch Chief, CDC Division of Healthcare Quality Promotion, “More than three-fourths of C. diff. infections in nursing homes occur within four weeks after a resident is discharged from an acute care hospital.” 

In the long-term care population, the number of C. diff. cases has risen to over 263,000 annually.  Although the annual C. diff. mortality count amongst the entire U.S. population is significantly less at 16,500, the percentage of these deaths occurring in people over age 65 has skyrocketed to 90%.  Considering these numbers only reflect reported cases of C. diff., we can estimate conservatively that between 4-6% of C. diff. patients in the LTC setting pass away prematurely from this preventable infection. 

Why focus on C. Diff?

C. diff. infections are a growing problem and of particular concern for the LTC community for a variety of reasons.  The clinical challenges and impending financial consequences, along with a target-rich patient population, should make C. diff. infections and infection control a top priority.  The idiosyncratic nature of C. diff., as opposed to other healthcare acquired infections (HAIs), also presents the necessity for a focused evaluation of infection control protocols.  Finally, while statistics demonstrate that as a whole, HAIs are trending downward as healthcare workers become more astute in prevention, containment and treatment; C. diff. has climbed to historic highs in recent years and remains a mystery to many seasoned and reputable caregivers.  The LTC community is beginning to realize that C. diff. is no longer a problem only in hospital settings and as the CDC recognizes, these infections are a patient safety concern everywhere medical care is provided. 

Clinical Challenges: Risk Factors for infection; Methods of transmission; and Prevention.

Richard Schwalberg, Administrator at Menorah Park, a large, multi-location, long term care network in Cleveland, Ohio, sums up the clinical challenges of preventing C. diff. simply and succinctly.  “Any healthcare worker who moves from room to room, such as nurses or housekeeping, has the potential to transmit the infection,” he begins, “The question is how much training are they getting in precautions and are they thinking about it on the job.” 

C. diff. is a bacteria that produces spores that can live for 30 days or more outside of the body and because the spores are resistant to traditional disinfectants, they can be readily spread throughout a LTC facility even while following standard infection control procedures.  Without proper precautions, the bacteria may be present on medical equipment and other surfaces long after a patient has recovered, moved to another room or even after discharge.  Researchers have reported C. diff. contamination on 10% to 50% of everything from bed sheets to electric thermometer and even on windowsills.  No surface in a room with a confirmed C. diff. patient is safe from the invasive spores. 

Once C. diff. spores are present, patients, caregivers, visitors, and even equipment moved in and out of the room become potential transmitters.  Under standard infection control procedures a quick wipe with an approved disinfectant, removing your gloves after an examination, or a dab of instant hand sanitizer may be enough to prevent further spread of most HAIs, but C. diff. lingers long after these precautions are implemented.  Alcohol, regular disinfectant solutions and hand sanitizers do not kill C. diff.  Chlorine-based agents with sporicidal action against the C. diff. spores have been approved to disinfect and prevent spread, but their caustic nature has prevented them from being universally embraced.  Recently, the EPA has approved a line of disinfectant products containing silver ions as an effective agent against C. diff.  The new product is non-corrosive and safe for use on delicate screens, probes and other medical equipment.  As mentioned before, while HAIs are being reduced largely in part to more effective standard infection control protocols, C. diff. containment requires a more target-specific approach to decontamination, so incidence of C. diff. infection and spread are increasing at an alarming and unacceptable rate.

Another increasingly evident factor in the struggle to prevent C. diff. is the lack of awareness the average healthcare worker has about the bacteria.  As Richard Schwalberg asked, “How much training are they getting in precautions and are they thinking about it on the job?”  Unless a facility deliberately trains staff on the differences between C. diff prevention and protocols versus standard HAI prevention and protocol, most LTC caregivers think traditional precautions are sufficient.  As we just demonstrated, these universally accepted standards fall short of what it takes to prevent C. diff.  In a recent study, 35 healthcare workers were tested for C. diff. after direct contact with an infected patient and 59% of them tested positive.  Two interesting lessons are learned from these results.  First, 59% of the healthcare workers failed at some point in preventing the spread of C. diff.  Second, with such a high percent of infected healthcare workers, why is the rate of C. diff. infection reported so low amongst them? 

A Target-Rich Population: LTC Patients and C. diff. infection

As mentioned above, C. diff. is often found in the normal intestinal flora of healthy individuals.  Our bodies keep the bacteria under control and we can go about our lives without incident.  For this reason, many healthcare workers that fail to take the necessary steps to guard against not only transmitting, but actually acquiring C. diff. are often non-symptomatic and are never reported as being infected.  However, the LTC population usually doesn’t get the same biological and beneficial hall pass. 

According to research, the major risk factors for developing C. diff. infection are:

     1.      Over age 65

     2.      Frail, elderly or otherwise not in perfect health

     3.      Compromised immune system

     4.      Recent history of antibiotics

Unfortunately, one or more of these factors may apply to most or all of an LTC population at any given moment.  To further complicate a risk assessment, in an LTC setting, the highest risk patients are those recently discharged from a hospital after a short-term rehabilitation or nursing stay.

Dr. Cliff McDonald assess the risk of the entire LTC population in terms of level of care, “In the 15,000 nursing homes in the United States we have a high percentage of patients who are sub-acute; and that’s the population most at risk for C. diff. because they have been primed with a lot of heavy duty antibiotics.”  Antibiotics kill the bacteria in the gut that normally prevent infection, leaving the path open for C. diff. to multiply. 

With a plethora of hosts that provide a rich environment for C. diff. to thrive and a lack of protocols to prevent it from spreading, the risk of an outbreak is looming for many LTC facilities. 

The cost of infection: C. diff. and bottom line impact

Although there have been many published reports of hospitals and LTC facilities implementing enhanced environmental cleaning and equipment decontamination in the past three years, many have yet to monitor and track the efficacy of the programs.  From a patient care perspective, implementing these and other infection control measures, even lacking a tracking element, is a win-win.  LTC facilities that successfully reduce HAI rates and provide an excellent patient experience gain a positive community reputation and gain the trust of local hospitals for referrals; both which are good for business and patients.  Until now, however, there hasn’t been a need to add the tracking element. 

In 2014 the Centers for Medicare and Medicaid Services (CMS) will require hospitals to report C. diff. infection rates and will partially weigh the annual payment update based on the results.  Currently, hospitals voluntarily submit data to avoid a 2% reduction in payment.  LTC experts believe the same financial carrot and stick will be implemented for LTC facilities.  Unacceptable C. diff. rates will eventually translate to reduced reimbursement.  The future success of LTC budgeting will be heavily influenced by C. diff. and other HAI rates and a proactive approach will include internal infection control strategy evaluation as well as HAI and C. diff. transmission protocols for contracted healthcare providers, such as mobile imaging, phlebotomy, and lab companies. 

Currently, even a C. diff. case that ends in recovery rather than fatality is a heavy financial burden on LTC facilities.  Reports estimate that each case may cost in the range of $5000 - $7000; adding up to $2.2 billion nationally.  By taking C. diff. prevention a step further, investing time and money now to bring the rate of incidence under control, an LTC facility could potentially save significant dollars all while adding to the strong community reputation and industry respect that ultimately drive the bottom line. 

Mobile Imaging Providers: Our role in C. diff. Prevention

A responsible imaging provider should be part of your solution to reduce C. diff. infections.  At Source Diagnostics, we are ahead of the pack for infection control, specifically C. diff. prevention and containment.  We have developed and implemented infection control protocols and all Source Diagnostics personnel are trained in our proprietary methods.  Our program is designed to protect your patients’ health and acknowledges the need for stronger awareness than standard infection control.  Our clients can expect that the Technologist or Sonographer entering their LTC facility is fully trained and compliant with our protocols.

As a leader in mobile imaging to the long term care industry, Source Diagnostics pushes the boundary of necessity and operates in the twilight of the rising sun.  We know what you need now, but we work to anticipate what is in store in the future.  For this reason, we are partnering with our clients as a resource for the multi-faceted approach necessary to comply with future CMS regulations.