Guideline:
Common infections in the long-term care setting
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Common infections in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2004. 34 p. [21 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Social Workers
Guideline Objective(s)
- To improve the quality of care for patients with common infections in the long-term care settings
- To guide care decisions and to define roles and responsibilities of appropriate care staff
Target Population
Residents of long-term care facilities
Interventions and Practices Considered
Diagnosis/Assessment
- Initial nursing assessment of a suspected infection including vital signs mental status lung sounds pulse oximetry dipstick urine test skin and wound examination bowel sounds stool and vomitus inspection and assessment of symptoms
- Assessment of risk factors for infection
- History physical examination and appropriate laboratory tests such as stool culture for enteric pathogens chest X-ray skin scrapings for suspected scabies urinalysis urine culture and sensitivity
- Assessing whether the patient's condition warrants transfer to a hospital
- Assessing whether the patient's condition warrants implementation of infection control precautions (standard and transmission-based)
Management/Treatment/Prevention
- Treating symptoms of infection including antifever medication (e.g. acetaminophen) monitoring nutritional status blood glucose levels in patients with diabetes volume depletion and electrolyte imbalance in patients with diarrhea
- Prescribing appropriate antibiotic therapy
- Monitoring patient's progress
- Containing and identifying outbreak of the infection
- Immunization program for all facility residents including influenza pneumococcal and tetanus/diphtheria vaccination
- Facility-wide infection control program including hygiene practices outbreak control procedures resident health programs and reporting of diseases to public health authorities
- Monitoring the management of infections in the facility using an effective infection control program
- Monitoring antibiotic use in the facility
Major Outcomes Considered
- Risk and incidence of common infections in the long-term care setting
- Morbidity and mortality related to infections in long-term care settings
- Incidence of transfer of patients with infections from long-term care settings to acute-care settings
- Health care costs
- Antibiotic resistant infections in the long-term care setting
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Interdisciplinary workgroups developed the guidelines using a process that combined evidence and consensus-based approaches. Workgroups included practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency association or organization such as the Agency for Healthcare Research and Quality (AHRQ) pertinent articles and information and a draft outline each group worked to make a concise usable guideline tailored to the long-term care setting. Because scientific research in the long-term care population is limited many recommendations were based on the expert opinion of practitioners in the field.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
All American Medical Director Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include American Medical Director Association physician members and independent physicians specialists and organizations that are knowledgeable of the guideline topic and the long-term care setting.
Major Recommendations
The algorithm Infection Management is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.
Clinical Algorithm(s)
An algorithm is provided for Infection Management.
Type of Evidence supporting the Recommendations
The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.
Potential Benefits
- Earlier identification and more appropriate treatment of patients with infection
- Fewer outbreaks and transmissions of infection within the facility
- A reduction in the inappropriate use of antibiotics
- A reduction in the number of patients with infections who are transferred to acute-care settings
- A reduction in direct and indirect patient care costs as a result of more appropriate resource utilization
Potential Harms
Adverse Effects of Medications
The use of antibiotics increases the risk for potentially harmful drug interactions in addition to the adverse effects associated with antibiotics themselves.
Qualifying Statements
- This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association and the American Health Care Association their heirs executors administrators successors and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use negligent or otherwise of this clinical practice guideline.
- The utilization of the American Medical Director Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and care-givers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician's ability to practice.
Long-term care facilities care for a variety of individuals including younger patients with chronic diseases and disabilities short-stay patients needing postacute care and very old and frail individuals suffering from multiple comorbidities. When a workup or treatment is suggested it is crucial to consider if such a step is appropriate for a specific individual. A workup may not be indicated if the patient has a terminal or end-state condition if it would not change the management course if the burden of the workup is greater than the potential benefit or if the patient or his or her proxy would refuse treatment. It is important to carefully document in the patient's medical record the reasons for decisions not to treat or perform a workup or for choosing one treatment approach over another.
Description of Implementation Strategy
The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.
- Recognition
- Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
- Assessment
- Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
- Implementation
- Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
- Identify individual responsible for each step of the CPG.
- Identify support systems that impact the direct care.
- Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
- Monitoring
- Evaluate performance based on relevant indicators and identify areas for improvement.
- Evaluate the predefined performance measures and obtain and provide feedback.
Facilities must implement a variety of strategies to control infections. Key indicators of an organizational commitment to infection control include the following:
- Establishment of an interdisciplinary infection control team that has designated leadership accountability and regular meetings
- Implementation of a comprehensive program to control identify and manage infections
- Routine admission assessment for tuberculosis and immunization status for pneumococcal pneumonia and influenza
- Standing orders for the administration of required immunizations on admission (if applicable depending on state law)
- Implementation of policies that encourage and facilitate regular hand washing (e.g. provision of waterless hand-sanitizing products monitoring of soap dispensers)
- Implementation of protocols to maintain residents' skin integrity (e.g. appropriate skin care accountability for turning residents and examining skin)
- Implementation of protocols for the prudent use of invasive devices (e.g. urinary catheters intravenous lines)
- Implementation of protocols that encourage prudent antimicrobial prescribing. In selected long-term facilities a more intensive antimicrobial utilization program may be developed including review of antibiotic appropriateness.
- Designation of an infection control coordinator who has sufficient time and appropriate training for the role
- Implementation of a staff training program in infection control
Implementation Tools
Clinical Algorithm
Tool Kits
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Common infections in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2004. 34 p. [21 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Medical Directors Association
Guideline Committee
Steering Committee
Composition of Group that Authored the Guideline
Hosam Kamel MD CMD Chair; Susan Levy MD CMD Co-Chair; Thomas Cali Pharm D; Pam Brummitt MA RDLD; Orchale Cook CNA; Paul Drinka MD CMD; Nancy H. Ferrone MS LN RD; Donna Gaber ICP; Lorraine M. Harkavy RN MS CIC; Carolyn L. Lehman MSN APRN BC NHA; Stephanie Lusis GNP; Niroshi Sharlene Rajapakse MD; Chesley Richards MD MPH; Jacqueline Rosati MSW; Karen Steinkruger BSN DON; Dan Weiler; Neddie Zadeikis MD MBA
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com
Availability of Companion Documents
The following are available:
- Guideline implementation: clinical practice guidelines. Columbia MD: American Medical Directors Association 1998 28 p.
- We care: implementing clinical practice guidelines tool kit. Columbia MD: American Medical Directors Association 2003.
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on March 14 2005. The information was verified by the guideline developer on April 19 2005.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. For more information please contact the American Medical Directors Association (AMDA) at (800) 876-2632.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
Tools
No Quick Reference tools have been developed.