In her presentation on March 30, 2017, at the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, Robin Jump, MD, PhD, assistant professor of medicine in the Division of Infectious Disease and HIV Medicine at Case Western Reserve University, physician-scientist at the Geriatric Research, Education and Clinical Center (GRECC), and the Louis Stokes Cleveland Veterans Affairs Medical Center, talked about the challenges associated with isolation precautions in long-term care settings, specifically nursing homes.
There are more than 15,500 nursing home facilities across the country, which care for about 1.4 million individuals daily, and 4.1 million annually. About 15% of those living in nursing homes are under 65 years of age, and approximately 40% are over 85 years of age. More than half of these individuals have dementia, and 5% to 25% are living with some sort of indwelling medical device.
“The other thing that’s special about this population,” said Dr. Jump, “is that they’re highly dependent on help for ADLs [Activities of Daily Living], bathing dressing, toileting, eating, and mobility.” More often than not, “This requires two people to get involved to do this, and that also means a lot more contact.” And the people who end up doing the “literal heavy lifting,” as Dr. Jump put it, is healthcare workers, nurses, and front-line staff.
One of the main challenges of isolation precautions in long-term care, according to Dr. Jump, is finding that “balance between personal rights and public safety.” For these patients, the facility is their home; it’s where they live. “We can’t tell someone that they must stay in their room for 6 weeks at a time. We encourage social interactions and recreation, there is the right to privacy even though we have two beds in a room a lot of the time, and there is often sexuality.”
However, since nursing homes can be reservoirs for multidrug-resistant organisms (MDROs), isolation is sometimes needed. In order to quality for reimbursement from the Centers for Medicare and Medicaid Services, nursing homes must submit Minimum Data Set (MDS) reports on all residents. In an analysis, resident MDS reports from over a 15-month period were examined. “Of the 4 million residents who were included in the study, 5% had an MDRO infection. We don’t know how many were actually colonized. The infection rate was truly the tip of the iceberg here.” Of the residents who were actually infected, 57% were found to have acquired infection from a nursing home, whereas 41% became infected at a hospital.
Dr. Jump drew on several different studies to estimate MDRO colonization rates in nursing homes. Colonization prevalence for methicillin-resistant Staphylococcus aureus
(MRSA) “may exceed 50%,” and approximately 25% of infected individuals may have acquired infection at the nursing homes. Prevalence of fluoroquinolone-resistant gram-negatives is “upwards of 50%,” with 17% of individuals having Extended Spectrum Beta-Lactamase (ESBL) bacteria, and 1% having carbapenem-resistent Enterobacteriaceae
, “which is really high in my opinion,” noted Dr. Jump. In terms of Clostridium difficile
, Dr. Jump estimates that “about 15% of nursing home residents may be asymptomatic carriers.”