How feasible are new SHEA guidelines on VRE?
More freedom of movement allowed
The Society for Healthcare Epidemiology of America (SHEA) has released a position paper on vancomycin-resistant enterococci (VRE) in long-term care facilities.1 Infection control practitioners say while new information on VRE in long-term care is welcome, they still must modify the SHEA recommendations, as well as guidelines from the Hospital Infection Control Practices Advisory Committee, to make them practical for use in long-term care facilities.2
Patti G. Grota, RN, MSN, CIC, CPHQ, infection control practitioner (ICP) for the South Texas Veterans Healthcare System’s geriatrics and extended care programs in San Antonio, says she and other ICPs implemented a modified version of the Centers for Disease Control and Preven tion’s contact precautions in 1995.3
"In the old days, when patients were on contact precautions, we put them in their rooms and shut the door," she explains. "We restricted visitors and only sent patients to diagnostic testing. We looked at that model and compared it to what we need in rehab, which is socialization, and tried to see how we could do both. The two things we changed were that we didn’t limit movement to the degree that you do in acute-care settings, and we looked at personal hygiene and whether the patient and family could be taught about washing their hands and how VRE is transmitted."
Grota and her colleagues performed a study on the prevalence of VRE and multidrug-resistant Klebsiella pneumoniae in the VA nursing home care unit, or extended care therapy center (ECTC). The study indicated that the prevalence of VRE was 2.8% (three of 109 patients had stool colonization) in the ECTC. A similar study for multidrug-resistant K. pneumoniae indicated its prevalence in 1996 was 12.2% (five of 41 patients were colonized).
"That [prevalence] was pretty low, but it was our wake-up call to VRE in our long-term care setting," says Grota.
To help implement rehabilitation goals and socialization among patients, the ICPs modified the CDC Guidelines for Isolation Precautions in Hospitals to allow freedom of patient movement, says Grota, including allowing some patients to perform their own personal hygiene measures. (See sample modifications, p. 131.) For example, one wheelchair-bound patient who has difficulty with personal hygiene but likes to move about the facility has his wheelchair cleaned by a light-duty nurse throughout the day; that helps avoid any incidences of possible cross-contamination. The nurse also washes his hands every four hours.
"He’s actually in a room with three other patients who have no invasive lines and are fairly bedridden, and we’ve not had any cross-transmission to them," Grota notes.
No more old ways’
A follow-up study in 1997 indicated that the prevalence of VRE was 3.8% (three of 79 patients), which was a slight increase from 1995. The prevalence of multidrug-resistant K. pneumoniae was 1.3% (one in 79 patients), which was a significant decrease from 1996. There was no cross-transmission of either organism identified.
Modifying contact precautions is in some ways more difficult than following older disease-specific isolation precautions, says Grota.
"In the old days, nurses didn’t have to make judgment calls," she explains. "You put a sign on the door, and it said enteric precautions.’ Whenever [nurses] touched stool, they wore gowns and gloves. It was very direct about what to use.
"With modified precautions, it takes treatment-planning conferences sometimes for us to figure out what to do with a particular patient. There’s more judgment involved. Does the patient have diarrhea? Is he colonized or infected? Does he have good hand and nail hygiene? The nurse has to make a more specific assessment about how the organism could be transmitted."
James F. Marx, RN, MS, CIC, an infection control and epidemiology consultant in San Diego, says that although the SHEA position paper makes good recommendations regarding issues such as patient and family education on VRE, some recommendations are not as applicable as they could be for long-term care facilities.
"I found the position paper to be too academic and not practical enough," he says.
Disinfection, cleaning ignored
In particular, Marx says although VRE is an organism found in stool, the SHEA statement doesn’t address the specifics of stool management in VRE patients. But he says he would have liked to have seen recommendations on issues such as cleaning and disinfection of bedpans and rectal thermometers. He also says many nursing homes use cloth diapers because they are less expensive, but that disposable diapers appear to pose less of a contamination risk to the environment. (See related story, p. 130.)
"What I recommend is disposable diapers," Marx notes. "If they don’t have disposable diapers, then what they need to have is a place to put the cloth diaper immediately after they remove it from the person so they don’t set it down on the bed or the floor. They should have a plastic bag there to put it into, and some facilities require that they rinse [cloth diapers] before they go to the laundry."
Interaction still important
He also says the SHEA statement doesn’t really address what to do with VRE patients during activities such as dining. As long as patients have good personal hygiene, they should be able to join other residents for some activities.
"You have to consider the quality of life of these patients," Marx says. "The person who is too restricted wouldn’t be able to even dine with other people. There’s too much of a leper mentality with people who have resistant organisms."
But Richard Garibaldi, MD, hospital epidemiologist at the University of Connecticut Health Center in Farmington and co-chair of the SHEA long-term care committee, says a private room is clearly preferable in some situations.
"With VRE, it’s very tricky, because most people are colonized because of gastrointestinal tract involvement," he says. "That’s where the colonization usually is. And one of the problems is that the environment gets contaminated fairly easily. Then people who come into the environment, be they visitors or health care workers, are likely to be passive carriers of the organism from one patient to another. If you have patients with diarrheal disease or who are unable to take care of their own personal hygienic needs, those are the people you should really emphasize to put in a single room. People who are attentive to cleanliness, you’re better able to put them in semiprivate rooms, because the likelihood of transmission is at least decreased."
Grota says although VRE isn’t as pathogenic as some other resistant organisms — especially in the nursing home setting — it still is important to follow contact precautions in patients who are colonized with it.
"My concern is that if we don’t practice with VRE, then when we get other organisms that are very difficult, we may get outbreaks," she says. "It may be intermediate Staph aureus resistance, but we need a practice round with our staff. If they don’t take caution with this, then we may get another drug-resistant organism . . . and then we’re going to get many patients with morbidity and mortality."
(Editor’s note: Marx maintains a Web site on infection control at www.broadstreetsolutions.com. In addition, the California Association of Infection Control Practitioners’ Coordinating Council maintains a Web site that includes antibiotic resistance guidelines at www.cacc.net.)
References
1. Society for Healthcare Epidemiology of America Committee on Long-Term Care. Vancomycin-resistant enterococci in long-term care facilities. Infect Control Hosp Epidemiol 1998; 19:521-525.
2. Hospital Infection Control Practices Advisory Com mittee. Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol 1995; 16:105-113.
3. Garner JS. Hospital Infection Control Practices Advis ory Committee. Guidelines for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content