American journal of Infection Control

Copyright © 2000 by the Association for Professionals in Infection Control and Epidemiology, Inc.

Volume 28(1) February 2000 pp 3-7

Effect of a comprehensive infection control program on the incidence of infections in long-

term care facilities
[Major Articles]

Makris, Alex T. MD, CMDa; Morgan, Louise RN, BS, CICc; Gaber, Donna J. BA, MTc; Richter,
Alan MSc; Rubino, Joseph R. MAb

Cherry Hill and Montvale, New Jersey, and Philadelphia, Pennsylvania

From The Department of Infectious Diseases, Our Lady of Lourdes Medical Center, Camden, New Jersey a;
DePaul Health Care, Philadelphia, Pennsylvaniab; and Research and Development, Reckitt & Colman,
Montvale, New Jersey.c
Products and financial support provided by Reckitt & Colman.
Reprint requests: Donna J. Gaber, BA, MT, Reckitt & Colman, One Philips Parkway, Montvale, NJ 07474.

Infectious diseases are a major problem for the institutionalized elderly. The incidence of
infections in longterm care facilities (LTCFs) is approximately 7.2 infections per 1000
resident care days.1 Results of 1-day prevalence studies indicate that the prevalence of
infection on the day of the study ranges from 1.6% to 32.7%.2 In general, the most
common types of infections seen in LTCFs are (1) urinary tract infections, (2) lower
respiratory tract infections-mainly pneumonia, and (3) skin and soft tissue infections,
principally cellulitis and infected pressure ulcers.3

Many host and institutional factors predispose and contribute to the higher incidence of
infections seen in LTCFs. Host factors include altered immunity, protein-calorie
malnutrition, and chronic medical conditions. Institutional issues include frequent staff
turnover in nursing and environmental services, limited reimbursement, and few
educational programs; these may result in inconsistent infection control practices.4-7
Considering all of these contributing factors, we set out to determine the impact of an
ongoing infection control intervention program in reducing the incidence of nosocomial
infections in LTCFs. The program stressed the importance of handwashing, provided
infection control education, and reinforced the importance of the regular cleaning and
disinfecting of environmental surfaces. In the 2-year study, infection rates for the
preintervention year were compared with infection rates for the intervention year in the
same 8 homes.

Materials and Methods

Study design and population

Eight private, freestanding LTCFs were selected for the study. The facilities were located
in New Jersey and Delaware. All were enrolled in the Medisys, Inc (an infection control
consulting firm) infection control surveillance program. The 8 facilities were selected on
the basis of similarity with respect to admission rate, size, acuity levels (intermediate and
skilled), availability of services (the same off-site laboratory and radiology service),
overall infection rates, and in-house environmental service departments. There were no
specialty units in any of the facilities. Resident populations were comparable in terms of
age, sex, and underlying disease. Risk stratification regarding mortality rates and length
of stay was not assessed. Immunization programs in all 8 facilities included influenza and
Pneumococcus prophylaxis.

Insofar as possible, the 8 facilities were grouped into 4 sets of matched pairs. Within each
pair, each home was designated at random as either a test site or a control site. The
result was that 4 facilities, 2 urban and 2 suburban, with a total of 443 beds, were
selected as test sites and another 4 facilities, 2 urban and 2 suburban, with a total of 447
beds, were selected as control sites.

Infection control preintervention meetings

Several visits were made to each of the 4 test sites before the initiation of the
intervention program. Meetings were held with test site administrators, infection control
nurses (ICNs), directors of nursing (DONs), assistant directors of nursing (ADONs), staff
development coordinators, and directors of environmental and dietary services. Existing
infection control policies were reviewed. Rounds were made to observe the frequency of
handwashing and compliance with isolation protocols and safe food-handling practices.
Cleaning and disinfecting techniques were also observed.

The 4 control sites followed their existing infection control policies. They did not change
disinfectant products (all used disinfectants) and were never visited by the sponsoring
study investigators.

Infection control preintervention education

No preintervention educational programs were provided for the control sites. Test sites
were provided with a 3-part, modular infection control educational program, the contents
of which had first been reviewed and approved by test site administrators. Each module
took approximately 40 minutes to present, with adequate time allowed for questions and
answers. Modules were presented approximately 2 to 3 weeks apart. Each test site
scheduled 2 presentations per shift per module, with all employees required to attend
one session.

Module 1 began by introducing the study's concept, purpose, and goals. The importance
of proper handwashing was presented through use of a black light demonstration
technique. In module 2, the chain of infection, disease transmission and prevention,
control of food-borne illnesses, and food safety tips were discussed. In module 3, a video
was presented that discussed the chemistry of cleaning and disinfecting environmental
surfaces and equipment. Procedures, equipment, and products used for cleaning and
disinfecting environmental surfaces were discussed. Suggestions for improving cleaning
techniques were made, such as dispensing freshly diluted disinfectant cleaning solution
with spray bottles and using a clean cloth in each room rather than a single cloth and a
dip bucket brought from room to room. These suggestions were implemented. Handout
material supporting each module was provided at the sessions.

Infection control intervention program product selection

The study design called for the germicidal products that the 4 test sites were using to be
removed and replaced with equivalent amounts of Lysol I.C. brand products for the 12-
month period of the intervention program. Replacement products included the following:
Lysol I.C. Antimicrobial Soap, Lysol I.C. Disinfectant Spray, Lysol I.C. Foaming Disinfectant
Cleaner, Lysol I.C. Toilet Bowl Disinfectant Cleaner, Lysol I.C. Quaternary Cleaner
Disinfectant, and Lysol I.C. No-Rinse Sanitizer. Test sites were also supplied with
disinfectant dilution stations and labeled spray bottles. The products selected by each
facility were introduced and discussed with the staff at the first inservice program and
then at subsequent training sessions as appropriate.

Follow-up during the Intervention program

Every 6 to 8 weeks, study investigators communicated with each test facility's director of
environmental and dietary services to ensure that the products were readily available
and were being used correctly. During the intervention period, each facility's ICN and
departmental directors were responsible for providing ongoing infection control and
product information lectures as staff changes occurred. A certified infection control
professional (ICP) from Medysis, Inc, provided on-site visits (n = 7) to all study facilities
during the study period. The purpose of these visits was to mentor the ICNs, increasing
their knowledge base, and to ensure mastery of the criteria-based total body surveillance
system. This system was in use in all 8 facilities before the study and is mandated in
LTCFs by the Health Care Finance Administration.8

Data collection

All 8 facilities used the same data collection work sheet. It identified (1) patient
demographic information (name, age, sex, unit, room number; and primary diagnosis),
(2) criterion for infection, (3) invasive devices, (4) causative pathogen, (5) antibiotic
therapy, and (6) body site of infection. The criterion used to determine the presence of
infection was printed on the reverse side of the work sheet for reference. In addition, all
ICNs were free to call for assistance in determining the presence of infection. A
combination of the Centers for Disease Control and Prevention (CDC) and McGeer
guidelines were used because the CDC criteria do not always apply to institutionalized
geriatric residents.

Traditionally, the position of ICN in long-term care is by assignment as an add-on to the

position of DON, ADON, or staff development nurse. None of the ICNs had had special
infection control training; however, as previously mentioned, all 8 ICNs had been
instructed in surveillance system data collection methods. Additionally, all 8 facilities
adhered to Body Substance Isolation guidelines.

Information about community-acquired and nosocomial infections was collected by all

facility ICNs on a concurrent basis. The consultant ICP was contacted when questions
arose concerning multidrug-resistant pathogens or precautionary measures. Work sheets
and weekly line listings were sent to Medysis, Inc, where they were reviewed for integrity.
All data were collated and analyzed at the consulting firm. Monthly infection control
reports were generated and sent back to all facilities for retrospective review. The
facilities received a monthly line listing that displayed information from the work sheet, a
chart exhibiting infections by location (nursing unit) and body site, a Pie chart, and
facility-specific threshold levels based on 1 year's retrospective data. Threshold levels
were calculated by establishing the mean number of infections and adding 1 SD.

Incidence rates (expressed as percentages) and incidence density rates (IDRs; expressed
as numbers of infections per 1000 patient days) were also provided as integral parts of
the report. Quarterly body site trend graphs were generated to provide prospective
trends in all facilities. The reports were analyzed to review monthly occurrences. Quality
improvement measures were offered to improve outcomes. All sites received these
reports (n = 12) throughout the study periods. In the test sites, quarterly infection control
environmental rounds were conducted by the ICN and the ICP consultant, and
recommendations for improvement were made as needed, especially in the
environmental services and dietary departments. No documented prolonged change in
behavior was noted in health care workers after the educational presentations or rounds.
These findings are consistent with the Hawthorne principle that direct observation will
preclude certain behaviors.

Statistical analysis

The repeated-measures design of this study allowed for the direct measurement of the
proportional (percentage) change in IDR from the preintervention year to the intervention
year within each site. The observed change in IDR within the control sites was assumed
to be due to a combination of random fluctuations in infection incidence and changes
(increases or decreases) in the community-acquired infection rate. The observed change
in IDR within the test sites was influenced by the same factors, as well as by whatever
effect the intervention program had. The effect of the intervention program could then be
estimated by comparing the percentage change in IDR at the test sites with that at the
control sites.

The IDR (infections per 1000 patient days) was calculated by dividing the total number of
infections of a given type (upper respiratory, etc) at a given home by the total patient
days and then multiplying by 1000. The percent change in IDR was calculated by
subtracting the preintervention year IDR from the intervention year IDR, dividing the
result by the preintervention IDR, and then multiplying by 100%.

To test the hypothesis that the intervention program had a beneficial effect on the IDR
(ie, a larger decrease or a smaller increase relative to the control homes), a 1-sided
Wilcoxon signed rank test was used. This nonparametric procedure was used because the
data cannot be assumed to have a normal distribution. It should be noted that because of
the small sample size, the highest level of confidence attainable using the Wilcoxon
procedure is 93.8% (ie, the smallest P value possible is .062). Therefore, significance at
the 95% confidence level could not be attained in this study no matter how dramatic the
observed differences between test and control sites.
The data were analyzed through use of Minitab statistical software (Minitab, Inc, State
College, Pa). The exact P values were obtained by comparing the computed Wilcoxon
statistic generated by the software with table values.9

RESULTS

Data were compared from all LTCFs during the preintervention and intervention years.
Pathogenic organisms were identified but have not been noted in the results of this study.
As shown in Table 1, during the preintervention period the test sites experienced a total
of 743 infections and had an IDR of 6.33 infections per 1000 patient days; the most
commonly seen infections were upper respiratory tract infection (n = 228) and
genitourinary tract infection (n = 215). In the same year, the control sites experienced a
total of 614 infections and had an IDR of 3.39 per 1000 patient days; the most commonly
seen infections were upper respiratory tract infection (n = 119) and genitourinary tract
infection (n = 187). (Asymptomatic bacteruria was found but not included as a
nosocomial infection.)

Table 1. Total infections and IDRs for test and control sites

During the intervention period, the test sites reported a total of 621 infections, with an
IDR of 4.15 per 1000 patient days; the number of upper respiratory tract infections went
down sharply (228 vs 99) whereas the number of genitourinary tract infections increased
slightly (241 vs 215). The control sites reported a total of 626 infections, with an IDR of
3.15 per 1000 patient days; the number of upper respiratory tract infections increased
slightly (143 vs 119), as did the number of genitourinary tract infections (250 vs 187).
Overall, the test sites experienced 122 fewer nosocomial infections during the
intervention year, whereas the control sites showed a slight increase. The number of
patient days remained relatively constant during the preintervention and intervention
years. Table 2 shows the intervention year median percent change by infection type for
test sites and control facilities. The most striking change approaching statistical
significance was in the number of upper respiratory tract infections (P = .06).

Table 2. Median percent change by infection type from preintervention to intervention years*

DISCUSSION

Because infections are a major cause of morbidity and mortality in the long-term care
setting, attempts to control infections have demanded increasing attention.2,10
Pneumonia is the most frequent cause of death in the institutionalized elderly.10,11
Muder et al 10 estimated that the cost of admission of a patient with pneumonia to an
acute care facility in 1992 was $14,600. Mor 12 calculated that treating moderate to
severe infections with a third-generation cephalosporin exclusively in the LTCF rather
than in an acute care facility saves $3,451.75 per treatment course.12 With the
emergence of drug-resistant organisms, the cost of treating moderately severe infections
in either health care setting will have to be reevaluated in the light of more costly
antimicrobials.
It is generally agreed that environmental cleaning and disinfecting, when done as part of
a comprehensive infection control program, may help reduce infections.13 Housekeeping
operations in hospitals and LTCFs are directed toward esthetics, safety, and the reduction
of infectious pathogens from environmental surfaces. The use of surface disinfectants in
LTCFs has been recommended by agencies such as the CDC and the Occupational Safety
and Health Administration.14,15 With the emergence of multidrug-resistant organisms
such as vancomycin-resistant enterococci (VRE) species, the use of effective
disinfectants in LTCFs may have even greater significance.16,17 Environmental
contamination in rooms of residents with VRE has been well documented.18,19 Cross
contamination with enterococci has been linked to contaminated fluidized beds.20
Frequent surface contamination with other nosocomial pathogens, such as methicillin-
resistant Staphylococcus aureus (MRSA) and Clostridium difficile, has also been
demonstrated.17,21 Studies by Sattar et al 22,23 provide evidence that fecal
contaminates, such as rotavirus, and droplet and airborne pathogens, such as
rhinoviruses, are found on and can be transferred from environmental surfaces. Studies
by Gwaltney 24 have demonstrated that self-inoculation from hand to nose or hand to
eyes with rhinoviruses from environmental surfaces can produce colds. Hendley and
Gwaltney 25 have shown that dispersal of rhinovirus may occur less frequently by the
aerosol route than by the manual route and that rhinovirus will survive in an indoor
environment for hours to days at ambient temperature.25 Recent data suggest that
surface disinfectants such as alcohol are very effective against rhinovirus and rotavirus
and that phenolics and quaternary ammonium compounds are effective against
VRE.23,26,27

In this small study, we used a broad-based infection control educational program along
with the regular use of disinfectants and cleaning solutions to observe whether this
combined approach could reduce the number of infections in test sites in comparison
with control sites. The most notable change seen was a decrease in the number of upper
respiratory tract infections in the test sites during the intervention period-there was a
median decrease of 58% in the test sites and a median decrease of 33% in the control
sites. Because these numbers were approaching statistical significance, we suspect that
a larger sample size would have made the results significant. It could be argued that this
reduction was due to significantly lower infection rates in the community. However, in the
2-year period of this study, the percentage of deaths caused by pneumonia or influenza
in the United State was actually higher during the study's intervention year.28

In a study similar to this conducted in a day-care setting, results showed a statistically

significant decrease in absenteeism caused by respiratory infections.29 LTFCs and day-
care centers share many of the characteristics that allow for the transmission of
infectious agents, including close personal contact between people and staff,
incontinence, diaper use, and a higher than normal prevalence of illness in the
population. The reason for the more noticeable decrease in respiratory infections in both
studies is not entirely clear and should be studied further.

We submit that infection control education that reinforces handwashing and other
hygienic measures helps reduce the numbers of organisms present on hands and
surfaces and may have contributed to the outcome of this study.

We thank Theresa Ritchie for her technical and administrative assistance on this project.

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