The Long-Term Care Infection Prevention Challenge

Long-term care facilities face unique infection prevention challenges. Residents are among the most vulnerable populations—elderly, immunocompromised, with multiple comorbidities, and often requiring invasive devices (urinary catheters, feeding tubes, central lines). The communal living environment facilitates transmission of infectious agents.

The statistics are sobering:

• 1.6 to 3.8 million infections occur in U.S. nursing homes annually (CDC)
• Urinary Tract Infections (UTIs): Most common HAI in LTC, affecting 10-20% of residents annually
• Respiratory Infections: Leading cause of hospitalization and mortality in LTC residents
• Skin and Soft Tissue Infections: Pressure ulcers, surgical site infections, cellulitis
• Gastrointestinal Infections: C. difficile, norovirus outbreaks
• Multidrug-Resistant Organisms (MDROs): MRSA, VRE, CRE increasingly common

This toolkit provides practical, evidence-based strategies to reduce infection risk, protect residents, and maintain compliance.

1. Hand Hygiene: The Foundation of Infection Prevention

Hand hygiene is the single most effective intervention for preventing healthcare-associated infections. Yet compliance in LTC settings averages only 40-60%—well below the 90%+ target.

The 5 Moments for Hand Hygiene (WHO Framework)

1. Before touching a resident
2. Before clean/aseptic procedures (wound care, catheter care, medication administration)
3. After body fluid exposure risk (even if gloves worn)
4. After touching a resident
5. After touching resident surroundings (bed rails, call button, etc.)

Hand Hygiene Supply Strategy

Alcohol-Based Hand Sanitizer (ABHS)

Placement Strategy: ABHS should be available within 5 steps of every point of care:

• Wall-mounted dispensers outside every resident room
• Portable bottles on all med carts and supply carts
• Pocket-sized bottles for all staff
• Dispensers at all nursing stations
• Dispensers in common areas (dining rooms, activity rooms)

Product Selection:

• Minimum 60% alcohol content (CDC recommendation)
• Moisturizing formulation to prevent skin irritation
• Fragrance-free options for sensitive residents/staff
• Foam or gel based on staff preference

Soap & Water

When Required: ABHS is not effective against C. difficile spores or when hands are visibly soiled. Soap and water required for:

• After caring for residents with C. difficile
• When hands are visibly dirty or soiled
• After using the restroom
• Before eating

Product Selection:

• Antimicrobial soap (chlorhexidine or triclosan) for high-risk areas
• Regular soap for general use
• Gentle formulations to prevent dermatitis
• Wall-mounted dispensers in all sinks

Improving Hand Hygiene Compliance

Environmental Strategies:

• Increase Access: Add more ABHS dispensers to reduce barriers
• Visual Cues: Posters and signs reminding staff of 5 moments
• Convenient Products: Pocket bottles, wearable dispensers
• Skin Care Program: Provide lotion to prevent dermatitis from frequent washing

Behavioral Strategies:

• Education: Regular training on importance and proper technique
• Observation & Feedback: Direct observation with immediate feedback
• Champions: Peer champions who model and encourage compliance
• Accountability: Include hand hygiene in performance evaluations
• Recognition: Celebrate units and individuals with high compliance

Monitoring Strategies:

• Direct Observation: Trained observers monitor and record compliance
• Product Usage Monitoring: Track ABHS consumption (target: 20-30 uses per resident day)
• Electronic Monitoring: Badge-based systems that track hand hygiene events
• Regular Reporting: Share compliance data with staff and leadership

2. Personal Protective Equipment (PPE) Programs

Appropriate PPE use protects both staff and residents from infection transmission. However, PPE is only effective when used correctly and consistently.

Standard Precautions: Universal PPE Use

Standard precautions apply to all residents, all the time, regardless of known infection status:

Glove Use

When Required:

• Any contact with blood, body fluids, mucous membranes, or non-intact skin
• Wound care and dressing changes
• Catheter care and insertion
• Handling contaminated items or surfaces

Key Principles:

• Change gloves between residents (never reuse)
• Change gloves between dirty and clean tasks on same resident
• Remove gloves immediately after use (don't wear in hallways)
• Perform hand hygiene after removing gloves

Product Selection:

• Nitrile gloves (latex-free to prevent allergies)
• Stock all sizes (XS through XXL)
• Powder-free to reduce respiratory irritation
• Budget for 8-12 glove changes per resident per day

Gown Use

When Required:

• Contact with residents on contact precautions
• Procedures likely to generate splashes or sprays
• Extensive wound care
• Bathing or toileting assistance for incontinent residents

Product Selection:

• Disposable isolation gowns for contact precautions
• Reusable gowns for routine care (more cost-effective and sustainable)
• Fluid-resistant for high-splash activities
• Size range to fit all staff

Mask Use

When Required:

• Caring for residents with respiratory infections
• During respiratory outbreak situations
• Sterile procedures
• As directed by facility policy (e.g., universal masking during flu season)

Product Selection:

• Surgical/procedure masks for standard use
• N95 respirators for airborne precautions (TB, measles, etc.)
• Ensure N95 fit testing program in place

Transmission-Based Precautions

Additional PPE required for residents with known or suspected infections:

PPE Supply Management for LTC

Calculating PPE Needs:

Formula: (# Residents × PPE Uses per Resident per Day × Days Supply) + Safety Stock

Example: 100-Bed SNF, 30-Day Supply

• Gloves: 100 residents × 10 uses/day × 30 days = 30,000 pairs + 20% safety stock = 36,000 pairs
• Gowns: 100 residents × 2 uses/day × 30 days = 6,000 gowns + 20% = 7,200 gowns
• Masks: 100 residents × 1 use/day × 30 days = 3,000 masks + 20% = 3,600 masks

Strategic Stockpiling Post-COVID:

Many LTC facilities now maintain 60-90 day PPE stockpiles after COVID-19 shortages:

• Store in climate-controlled area
• Rotate stock to prevent expiration
• Conduct quarterly inventory audits
• Establish supplier agreements for emergency replenishment

3. Standardized Infection Prevention Packs

Pre-assembled infection prevention packs ensure staff have everything needed for proper precautions, reduce setup time, and improve compliance.

Essential Infection Prevention Packs

1. Contact Precaution Cart/Pack

Contents:

• Isolation gowns (10-20)
• Nitrile gloves, all sizes (50-100 pairs)
• Surgical masks (20-30)
• Hand sanitizer (500ml bottle)
• Disinfectant wipes (canister)
• Red biohazard bags
• Precaution signage for door

Placement: Outside room of resident on contact precautions

2. Wound Care Kit

Contents:

• Sterile gloves (multiple sizes)
• Sterile gauze pads (4×4, 2×2)
• Normal saline (for irrigation)
• Wound cleanser
• Various dressings (foam, hydrocolloid, alginate)
• Medical tape and securing devices
• Disposal bag
• Wound measurement tool

Usage: Standardizes wound care approach, ensures proper supplies available

3. Urinary Catheter Care Kit

Contents:

• Sterile gloves
• Catheter care wipes or solution
• Sterile water or saline
• Drainage bag
• Securing device
• Catheter care checklist

Usage: Daily catheter care, reduces CAUTI risk

4. Respiratory Hygiene Station

Contents:

• Surgical masks
• Tissues
• Hand sanitizer
• No-touch waste receptacle
• Respiratory hygiene signage

Placement: Facility entrance, waiting areas, common spaces

5. Isolation Room Setup Kit

Contents:

• Complete PPE for 24 hours (gowns, gloves, masks)
• Dedicated equipment (stethoscope, BP cuff, thermometer)
• Disinfectant supplies
• Biohazard bags
• Precaution signage
• Visitor instruction sheet

Usage: Rapid setup when resident requires isolation

4. Environmental Cleaning & Disinfection

Environmental surfaces in LTC facilities harbor pathogens that can transmit to residents. Proper cleaning and disinfection are essential.

High-Touch Surface Cleaning Protocol

High-Touch Surfaces (Clean 2-3x Daily):

• Bed rails and controls
• Over-bed tables
• Call buttons and remotes
• Door handles and light switches
• Bathroom fixtures (toilet, sink, grab bars)
• Wheelchair arms and controls
• Walker handles

General Surfaces (Clean Daily):

• Floors
• Walls
• Windows and windowsills
• Furniture
• Medical equipment

Disinfectant Selection & Use

EPA-Registered Hospital Disinfectants

Use only EPA-registered products with claims against relevant pathogens:

• Broad-Spectrum: Effective against bacteria, viruses, fungi
• C. difficile: Bleach-based or EPA List K products for C. diff areas
• Contact Time: Follow manufacturer's instructions (typically 1-10 minutes)
• Compatibility: Safe for surfaces being cleaned

Cleaning Supply Carts

Standardize cleaning carts for consistency and efficiency:

• EPA-registered disinfectant (spray and wipes)
• Microfiber cloths (color-coded: blue for general, red for bathrooms)
• Mop and bucket
• Gloves and PPE
• Waste bags
• Cleaning checklist

Terminal Cleaning Protocol

When resident is discharged or transferred, conduct thorough terminal cleaning:

1. Remove all items: Linens, personal items, disposable supplies
2. Clean from top to bottom: Ceiling, walls, fixtures, furniture, floor
3. Disinfect all surfaces: Use appropriate contact time
4. Clean and disinfect equipment: Bed, mattress, wheelchair, etc.
5. Replace curtains and privacy screens
6. Final inspection: Verify cleanliness before next resident

5. Device-Associated Infection Prevention

Invasive devices (urinary catheters, feeding tubes, central lines) are major infection risks in LTC. Evidence-based protocols can dramatically reduce device-associated infections.

Catheter-Associated UTI (CAUTI) Prevention

UTIs are the most common HAI in LTC, and most are associated with urinary catheters.

CAUTI Prevention Bundle:

1. Avoid Unnecessary Catheterization: Use catheters only when medically necessary, not for staff convenience
2. Proper Insertion Technique: Sterile technique, appropriate size, adequate lubrication
3. Secure Catheter: Prevent movement and urethral trauma
4. Maintain Closed System: Don't break drainage system unnecessarily
5. Keep Bag Below Bladder: Prevent backflow of urine
6. Daily Catheter Care: Clean meatus with soap and water daily
7. Daily Assessment: Is catheter still needed? Remove as soon as possible

CAUTI Prevention Supply Kit:

• Sterile catheter insertion kits (various sizes)
• Sterile gloves
• Catheter securing devices
• Catheter care wipes or solution
• Drainage bags (bedside and leg bags)
• CAUTI prevention checklist

Central Line-Associated Bloodstream Infection (CLABSI) Prevention

While less common in LTC than hospitals, some SNFs care for residents with central lines (PICC lines, ports).

CLABSI Prevention Bundle:

1. Hand Hygiene: Before and after all line access
2. Maximal Barrier Precautions: Full sterile technique for dressing changes
3. Chlorhexidine Skin Prep: 2% CHG for site cleaning
4. Optimal Site Selection: Avoid femoral lines when possible
5. Daily Line Necessity Review: Remove when no longer needed
6. Dressing Changes: Per protocol (typically every 7 days or when soiled)

CLABSI Prevention Supply Kit:

• Sterile gloves and gowns
• Sterile drapes
• 2% chlorhexidine prep sticks
• Transparent dressings
• Alcohol prep pads
• Needleless connectors
• CLABSI prevention checklist

6. Outbreak Preparedness & Response

LTC facilities are particularly vulnerable to infectious disease outbreaks due to close living quarters and vulnerable population. Rapid response is critical to contain spread.

Common LTC Outbreaks

• Influenza: Annual winter outbreaks, high mortality in elderly
• Norovirus: Highly contagious gastroenteritis, rapid spread
• C. difficile: Antibiotic-associated diarrhea, environmental contamination
• Scabies: Skin infestation, difficult to eradicate
• MRSA: Multidrug-resistant skin and soft tissue infections
• COVID-19: Respiratory illness with high morbidity/mortality in elderly

Outbreak Response Supply Kit

Maintain a dedicated outbreak response kit that can be rapidly deployed:

PPE Surge Supply (30-Day):

• Isolation gowns (500-1,000)
• Gloves (10,000+ pairs)
• Surgical masks (1,000+)
• N95 respirators (500+, if airborne pathogen)
• Face shields (50-100 reusable)

Cleaning & Disinfection:

• EPA-registered disinfectant (appropriate for pathogen)
• Bleach for C. difficile or norovirus
• Microfiber cloths (100+)
• Mop heads (20-30)
• Disinfectant wipes (multiple canisters)

Resident Care:

• Thermometers (dedicated to outbreak unit)
• Specimen collection supplies
• Medications (antivirals, antibiotics as appropriate)
• Hydration supplies (IV fluids, oral rehydration)

Communication & Documentation:

• Outbreak investigation forms
• Line listing templates
• Staff/family notification templates
• Signage (visitor restrictions, precautions)

Outbreak Response Protocol

Detection & Activation (Day 1):

• Identify cluster of cases (2+ residents with similar symptoms)
• Notify infection preventionist and administrator
• Activate outbreak response team
• Begin line listing (tracking all cases)

Containment Measures (Days 1-3):

• Implement transmission-based precautions for all cases
• Cohort affected residents (group together if possible)
• Restrict admissions and transfers
• Cancel group activities and communal dining
• Implement visitor restrictions
• Increase environmental cleaning frequency

Investigation & Control (Days 3-7):

• Identify pathogen through testing
• Determine source and mode of transmission
• Implement pathogen-specific control measures
• Screen all residents and staff for symptoms
• Notify health department per regulations

Resolution & Prevention (Days 7+):

• Continue precautions until outbreak declared over (typically 2-3 incubation periods after last case)
• Conduct terminal cleaning of affected areas
• Review outbreak response and identify improvements
• Update policies and procedures based on lessons learned
• Replenish outbreak supply kit

7. Staff Education & Competency

Supplies and protocols are only effective if staff are trained and competent in their use.

Required Training Topics

Initial Orientation (All New Staff):

• Infection prevention principles and chain of infection
• Hand hygiene: when, how, and why
• Standard precautions and PPE use
• Transmission-based precautions
• Cleaning and disinfection procedures
• Outbreak recognition and response
• Regulatory requirements and facility policies

Annual Competency Assessment:

• Hand hygiene technique observation
• PPE donning and doffing demonstration
• Isolation room setup
• Device care procedures (catheter, wound, etc.)
• Knowledge test on key concepts

Just-in-Time Training:

• New product introductions
• Policy or procedure changes
• Outbreak response activation
• After infection control deficiency identified

Training Methods

• Classroom Education: Formal sessions with presentations and discussion
• Hands-On Demonstrations: Practice PPE use, hand hygiene, device care
• Simulation: Mock outbreak scenarios to practice response
• E-Learning: Online modules for flexibility and documentation
• Competency Validation: Direct observation and assessment
• Huddles: Brief daily or weekly reminders and updates

Partner with LAC Health for LTC Infection Prevention

LAC Health understands the unique needs of long-term care facilities and provides comprehensive infection prevention support:

🛡️ Infection Prevention Supply Solutions

• Custom infection prevention packs designed for LTC workflows
• PPE programs with volume pricing and surge capacity
• Outbreak response kits ready for rapid deployment
• Device care bundles (CAUTI, CLABSI prevention)

📚 Education & Training Resources

• Staff training programs and materials
• Competency assessment tools
• Infection prevention best practice guides
• Webinars and educational sessions

📊 Compliance & Monitoring Support

• Regulatory requirement tracking
• Infection prevention program assessment
• Supply usage analytics and optimization
• Benchmarking against peer facilities