Surveillance and Control of Infections in Long-Term Care: The Canadian Experience BEVERLY CAMPBELL, R.N., B.SC.N., M.Ed., Ottawa, Canada

In 1980, the Laboratory Centre for Disease Control, Health Protection Branch, Depart- ment of National Health and Welfare Can- ada, established the Bureau of Infection Control in response to a growing need for an infection control resource at the na- tional level. Until that time, there had been no federal programs in Canada for surveil- lance and control of infections in health care facilities. Initial efforts in the develop- ment of infection control programs focused on acute care facilities. In 1985, a specific need was identified to develop better sur- veillance and control of infections in long- term care facilities. Several national initia- tives have been undertaken to meet this need, including the preparation and publi- cation of an infection control guideline spe- cifically for long-term care facilities, a na- tional survey of Canadian long-term facilities, and the stimulation of research to evaluate new criteria for nosocomial infec- tions in a selected number of Canadian long-term care facilities.

From the Division of Infection Control, Laboratory Centre for Disease Control, Health and Welfare Canada, Ottawa, Ontario, Canada.

Requests for reprints should be addressed to Beverly Campbell, R.N., B.Sc.N., M.Ed., Division of Infection Control, LCDC, Health and Welfare Canada, Room 530, Brooke Claxton Building, Tunney’s Pasture, Ottawa, Ontario KIA OLZ, Canada.

D uring the past decade, there has been a considerable amount of information pub-

lished on the surveillance, prevention, and control of infections in acute care facilities [l-51. In long- term care facilities, however, where infection can be a common cause of death in residents, informa- tion is limited on the presence and impact of infection control programs in preventing transmis- sion of infections.

In 1980, the Laboratory Centre for Disease Control, Health Protection Branch, Department of National Health and Welfare Canada, established the Bureau of Infection Control, now the Division of Infection Control of the Bureau of Communica- ble Disease Epidemiology, in response to a growing need for an infection control resource at the na- tional level. Until that time, there had been no federal programs in Canada for surveillance and cantrol of infections in health care facilities. The mandate of this Division, therefore, has been to assist health care facilities in the development of infection control programs; the Division has no legislative authority.

Initial efforts focused on acute care facilities and the preparation and publication of a set of guide- lines pertinent to infection control in these facili- ties. In September 1985 [61, however, following a very serious nosocomial outbreak in a long-term care facility, a specific need was identified for assistance in developing mechanisms to provide better surveillance and control of infections in these facilities. As a result, several national initia- tives were undertaken by the Division to meet this need including: (a) the preparation and publication of an infection control guideline specifically for long-term care facilities [71; (b) a national survey of Canadian long-term care facilities [81; and (c) the stimulation of research by contracting a study to evaluate new criteria for nosocomial infections in a selected number of Canadian long-term care facili- ties [91.

INFECTION CONTROL GUIDELINES FOR LONG-TERM CARE FACILITIES

The primary objective in developing clinical guidelines at the national level is to assist health care professionals in improving the quality of

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patient care. Guidelines for the control of infection are needed to assist in developing policies, proce- dures, and evaluative mechanisms in order to ensure an optimal level of care.

The Division of Infection Control, under the guidance of a National Steering Committee on Infection Control Guidelines Development, identi- fies the need for a specific guideline, establishes a priority for its development, then prepares, ap- proves, and publishes the document. This Steering Committee is composed of infection control experts from across Canada, and different working groups are organized for the development of each specific guideline. When published, the guidelines are dis- tributed free on request.

In 1986, an infection control guideline for long- term care facilities was published and distributed by the authority of the Minister of National Health and Welfare. This guideline contains information related to the organizational structure of the infec- tion control programs in these facilities and pre- sents a brief protocol for outbreak investigations. Environmental concerns such as the handling and care of equipment and supplies, food services, housekeeping, and waste disposal are also dis- cussed. In addition, there is information on the management of specific care situations, such as those involving catheters, eyes, and infestations. The guideline concludes with a section on occupa- tional health.

During the 4 years that this document has been in use, it has become evident that there is an additional requirement to make the guideline more consistent with current needs and resources and to make the terminology more representative of the situations in these facilities. This guideline is currently being revised and modifications will re- flect what has been learned during the 4 years that it has been in use. The importance of closer communication with public health authorities will also be emphasized and new definitions of infection specifically developed for long-term care facilities will be included.

Although this guideline has been distributed widely across Canada, the Division of Infection Control has no information regarding its use. One of the Division’s goals for the immediate future is to evaluate the extent of its use and to determine if there are now infection control practitioners in those institutions that have adopted the guideline.

NATIONAL SURVEY OF CANADIAN LONG-TERM CARE FACILITIES

The overall objective of this study was to deter- mine the scope of infection control programs and personnel in Canadian long-term care facilities.

More specifically, the survey hoped to determine the following:

o The extent of surveillance programs in these facilities

l The type of laboratory support available o The educational needs of individuals responsi-

ble for infection control o The occurrence of outbreaks of infection and

their investigation l The extent of isolation policies and practices

in these facilities A stratified random sample of 1,358 facilities

was selected from a total list of 2,983 compiled and verified by the Canadian Long-Term Care Associa- tion. To provide a proper geographical representa- tion, a disproportionate allocation scheme was used to obtain the sample. A questionnaire was prepared and mailed to each of the facilities in- volved in the survey in the late spring of 1987. In those instances in which there was no response, a second mailing was done followed by telephone contact as required. Six hundred and fifty facilities responded, giving a somewhat lower than expected response rate of 48%. The response rate varied dramatically from one area of the country to another, and analyses were adjusted accordingly. No attempt was made to validate responses.

From this survey, it was determined that Cana- dian long-term care facilities, in general, have an average of 89 residents, with the average age being 78 years. One third of these residents were consid- ered completely dependent on facility staff to carry out normal activities of daily living. Activities of daily living were defined as bathing, dressing, eating, toiletting, transferring, and ambulating.

Written infection control policies were available in 54% of these 650 facilities. Forty-one percent reported infection control committees and 56% of these committees met at least quarterly. Surpris- ingly, the committee chairperson was most often a member of the nursing staff (39%), followed by a member of the medical staff (24%).

Forty-four percent of the responding facilities reported a designated individual responsible for infection control. However, 70% of these positions were part-time and 93% were combined with re- sponsibilities other than infection control. Forty- two percent of these positions reported to the administrator, and 32% to the director of nursing. Sixty-five percent of the facilities indicated that a physician was available for infection control consul- tation.

Almost two thirds (63%) of the facilities had written isolation policies. Single rooms for isola- tion were available in 57% of the facilities and 49% of these had separate ventilation. Although resi-

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dents do not often require isolation rooms for respiratory diseases, this finding does mean that proper air control was not available in half of the responding facilities. Forty percent of the facilities indicated that they had a written protocol to follow should an outbreak occur; however, only 21% reported having had a nosocomial outbreak. No information was received on the types of outbreaks or their frequency.

The amount of time devoted to infection control by the designated person was low, less than 5 hours per week. Moreover, only one third of the infection control practitioners reported having at- tended a course devoted to infection control issues and practices. It should be noted, however, that, currently, there are only a few educational pro- grams available specifically designed for infection control practitioners in long-term care facilities. It is quite clear that educational programs for person- nel in acute-care facilities do not meet the needs of those involved in infection control in long-term care facilities.

facilities and to determine the incidence of nosoco- mial infections in a sample of these facilities. The definitions used in this study were derived at a consensus conference held in January 1989, and subsequently revised by a modified Delphi tech- nique involving consensus conference participants. The data collection phase of this study involving 600 residents in 10 long-term care facilities in Ontario has just been completed and the results are expected to be available soon.

The reliability and validity of the definitions have been tested through the collection of inci- dence data on nosocomial infections in the sample of long-term care facilities in Ontario, Data col- lected on the infection control procedures in the sample facilities and resident risk factors will be used for future studies of risk factors for infection and to compare the sample population with other populations.

In Canada there are no regional regulations that would influence the existence of an infection con- trol committee in these facilities. The Canadian Council on Health Facility Accreditation, however, has developed standards, including those specific for infection control, which must be met for facili- ties to be accredited. These standards require an infection control committee and infection control policies. In this survey, just over one third of the responding facilities were accredited, and a large proportion of the remainder were planning to do so. This will definitely have a significant impact on infection control practices in Canadian long-term care facilities in the future.

In summary, the infection control needs of Cana- dian long-term care facilities have been well recog- nized and, as a result, the Laboratory Centre for Disease Control has been actively involved in the development of guidelines and educational pro- grams for personnel in these facilities. A standard- ized reliable set of definitions will allow additional multicenter studies of factors predisposing to infec- tions in residents of long-term care facilities to be carried out and programs for the control of these infections to be put in place. Such definitions will also be useful for national and provincial surveil- lance of infections in these facilities. The promo- tion of research to ensure development of appropri- ate programs for the surveillance and control of infections in long-term care remains a priority.

Information obtained from this survey indicated that some effort is being made in the area of infection control in long-term care facilities, but that much more is required. Perhaps present effective acute care surveillance, prevention, and control programs should be modified to meet the needs of long-term care facilities. The findings also indicated an urgent need for educational programs designed specifically to meet the requirements of the infection control practitioner in the long-term care setting.

REFERENCES

RESEARCH ACTIVITIES In 1988, the Laboratory Centre for Disease

Control solicited proposals to investigate the neces- sity for, and the value of, surveillance of infections in long-term care facilities. The objectives of this study were to assess the reliability, acceptability, and validity of a set of definitions in long-term care

1. Losos J, Trotman M. Infection control practices in Canadian hospitals. Am J Infect Control 1984; 12: 289-92. 2. Losos J, Trotman M, Campbell B. Profile of infection control practitioners in Canadian hospitals. Am J Infect Control 1984; 12: 325-8. 3. Campbell BA, McCunn SM, Trotman M, Wells GA. The infection control practitioner in Canadian hospitals with more than 200 beds. Am J Infect Control 1984; 12: 224-8. 4. Thompson RL. Surveillance and reporting of nosocomial infections. In: Wenzel RP (ed). Prevention and control of nosocomial infections. Baltimore: Williams&Wilkins, 1987: 70-82. 5. Haley RW, Cluver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985; 121: 182-205. 6. Carter AO, Borezyk AA, Carlson JAK, et al. A severe outbreak of Escherichia co/i 0157:H7-associated hemorrhagic colitis in a nursing home. N Engl J Med 1987; 317: 1496-500. 7. Health and Welfare Canada. Infection control guidelines: long-term care facilities. Ottawa, Ontario: Health and Welfare Canada, 1986. 8. Campbell BA, Wells GA, Rahman M. Infection control in Canadian long-term care facilities. infect Control Can 1989; 4: 6-12. 9. McGeer A, Campbell B, Emori G, et a/. Definitions of infection for surveillance in long-term care facilities. Am J infect Control 1991; 9: 1-7.

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