One-on-one with… Phenelle Segal, RN, CIC

Resistant strains of infections, such as Methicillin-resistant staphylococcus aureus (MRSA), Carbapenem-resistant Enterobacteriaceae (CRE) and extended-spectrum β-lactamases (ESBL) are growing problems in skilled nursing, fueled by the rising resident acuity and a long culture of antibiotic overuse. But the old blame game between acute care and nursing homes is passe now, and long-term care is learning to shoulder a greater responsibility in controlling the transmission—and creation—of healthcare-acquired infections (HAIs).

 

Editor-in-Chief Pamela Tabar recently spoke with Phenelle Segal, RN, CIC, one of the nation's leading experts in infection prevention within long-term care (LTC) environments. Segal, president of Infection Control Consulting Specialists, Delray Beach, Fla., is a passionate participant in both clinical education and federal initiatives. She is a task force member of the Health and Human Services National Action Plan to Prevent Healthcare-Associated Infections, and assisted the Association for Professionals in Infection Control and Epidemiology (APIC) with review of the current Guideline to Elimination of C. difficile Infections in Health Care Settings, released in 2013. She also consults skilled nursing facilities on antibiotic stewardship and infection prevention.

 

Antibiotic stewardship is one step in the greater process of infection prevention. Antimicrobials are the most frequently prescribed class of drugs in nursing homes, so it's extremely important for LTC facilities to engage in responsible planning and management of antibiotics. Antibiotic stewardship programs in long-term care need to involve multiple disciplines—nursing, the medical staff and the pharmacists.

 

If you overload a resident with antimicrobials, you are creating resistance patterns. MRSA and other MDROs exist because we use too many antibiotics and use them injudiciously. In the long-term care setting, we're seeing far too many antibiotics being used for inappropriate reasons. Nursing homes have many issues that aren't factors in acute care, but our poor practices have contributed to the problem. The Centers for Disease Control and Prevention estimates that 25 to 75 percent of antimicrobial use may be inappropriate. Too many nursing homes run for the antimicrobials each time a resident sneezes or has a mental status change, because they're so afraid of the liability of possible pneumonia and urinary tract infections. It's a culture problem. But MDROs are a very serious situation now. CRE was unheard of five years ago, but now it's showing up in long-term care. The problem is, there are no approved antimicrobials to treat these infections, and people are dying.

 

The times have definitely changed, especially in the past few years. CMS is stepping up its efforts to make a lot of this mandatory, and many more efforts are taking place at every level. Individual LTC facilities are understanding the critical need to step up their practices. The rising acuity within nursing homes makes it easier for residents to acquire these organisms, either from a hospital or another facility. But because of poor practices within the nursing home, we can spread the infections to other residents who have not been in a hospital. The controls necessary are far more difficult to maintain in communal living than in acute care. Resident isolation can be very challenging, but it's necessary. Yet, it's not about who's to blame for transferring these organisms from one facility to another; it's about how you handle the control within your own facility.