1. David R. Woodard, MSc, CIC, FSHEA
Infection Prevention in Behavioral Health Centers and Long Term Care Facilities
David R. Woodard, MSc, CIC, FSHEA

2. Behavioral Health Types of facilities Freestanding
Integrated into acute care hospitals
Specialty psychiatric hospitals
Substance abuse centers
Outpatient practices
Group homes
Correctional institutions

3. HAI in the BH arena
Usually related to the human interactions of milieu therapy
Usual treatment:
topical
oral medications

4. Common sites of Infection
Ophthalmologic Ears, nose, throat, Mouth (Dental) Upper respiratory tract; Skin and soft tissue NHSN case definitions are useful when assigning site

5. Chain of Infection
The adaptation of infection prevention to the behavioral health setting can be achieved by addressing the six links in the chain of infection: organism, reservoir, portal of exit, susceptible host, portal of entry, method of transmission.

6. Breaking the Chain

7. Overview Infection Prevention Plan Risk Assessment Surveillance Plan
Job Description of IP
Competency Assessment
Infection Control Committee
Authority Statement
Issues Unique to BH and LTC

8. Goal of IP Program
Decrease the risk of infection to patients and personnel
Monitor the occurrence of infection
Implement appropriate control measures
Identify and correct problems
Maintain compliance with state and federal regulations and standards

9. Scope of the IP Program Variables: Patient population
Specialized needs
Healthcare facility
Geographic location of the facility
Local epidemiology
Catchment area

10. Surveillance of HAIs Patients/clients Employee
Specific reporting to state and NHSN
CAUTIs
Reportable diseases
CLABSIs in rehab facilities
Influenza immunization rates

11. Outbreak Investigations
Attentive IP
Naïve staff
Examples of BHC and LTC outbreaks
Infestations TB
Norovirus and other GI infections
MRSA and other skin and soft tissue infections
Respiratory viral infections
MMR, Chickenpox

12. Policy and Procedures
Systematic review on regular schedule (i.e. every three years)
Equipment cleaning procedure
Prevention procedures for HAIs
Environmental disinfection
Instrument and equipment reprocessing
Hand Hygiene
Proper use of PPE
Isolation and Precaution techniques
MDRO procedures

13. Staff Development/Education
New employee orientation
On-going education and in-service
Hand hygiene campaigns
MDRO education and new pathogen alerts
Newsletters
Focused education
Sharing at unit level

14. Facility Consultant Isolation and precautions
Management of patient and staff exposures to communicable diseases
Environmental issues (floods, sewage back-up)
Emergency preparedness
Employee health issues
Laboratory results
Disinfection and sterilization
Antiseptics, antimicrobials and aseptic technique

15. IP Committee or Committee of the Whole
Meet on a regular basis (every two months)
Approves policies and procedures
Approves disinfectants and antiseptics
Reviews surveillance data
Develops action plans based on surveillance
Reviews employee health stats (needlesticks, exposures, PPD skin testing, influenza)

16. IP Reporting Reports to the ICC Reports to the medical doctor
Reports feedback to staff
Reports to C Suite (CEO, CNO, etc)
Reports to the Employee Health service

17. Infection Prevention Plan
Risk Assessment (review quarterly)
Review annually
Reflect changes in population, services
Progress in HAI reduction
Establishes goals/objectives
Identifies program needs
Assesses previous year goals

18. IP Competency Assessment
Management
Basic principles of management
Steps in problem-solving process
Concepts of change theory
Education
Principles of adult education
Conducting a needs/knowledge assessment
Educational techniques and methods for adults
Learner evaluation techniques
Teaching strategies

19. IP Competency Assessment
Surveillance
Principles of epidemiology
Surveillance methods
Criteria for HAIs per NHSN
Basic statistical calculations
Descriptive epidemiology and presentation
Reporting mechanisms
Outbreak Detection and Management
Steps in outbreak investigation
Detection of trends, clusters, outbreaks
State or federal reporting requirements
Methods to obtain assistance with an outbreak

20. IP Competency Assessment
Policies and Procedures
Organization’s policy/procedure format
Ability to develop policies and procedures
Consultation
Effective communication
Access and knowledge of resources for IP measures, standards, regulations and recommended practices

21. Collaboration with Departments
Department managers within the organization
Organizational leadership
Committees/Teams
Occupational Health
Policies and procedures
Infection prevention processes
Communicable diseases, incubation periods, periods of communicability, prophylaxis
Regulatory requirements

22. Qualifications for IPs
Attendance at a basic training program
Structured mentoring by an experienced IP
Certification in Infection Control or preparation for CIC
Establishes a network of other local IP
Participates in on-going services
Participates in meetings, conferences specific to infection prevention and epidemiology
IP will probably also be the Employee Health Nurse

23. Psychiatric Hospital Patient Environment
Units with semi-private rooms
Patients are not confined to rooms or beds
Comingle in open areas
Community bathroom and shower facilities
Group activities and therapy
Meals served in a cafeteria setting
No isolation rooms
No negative pressure rooms
Upholstered furniture and carpet in common areas
No alcohol based hand sanitizers on patient care units

24. Infection Control Acute Care heightened concerned with
VAPs
CAUTIs
SSIs
C diff
MDRO
CLABSI
Behavioral Health heightened concerns with: TB
Head and Body Lice
Infestations
Fungal infections
Norovirus
Clients personal hygiene

25. Issues Screening clients upon admission (to POU)
Environmental Services
Unique challenges (carpets, upholstered chairs)
Employee Health
Administrative Controls
PPE
Reportable Diseases
Patient compliance
ASP

26. Categories of Infections in BH
Community Acquired any infection or infestation that is present or incubating at the time of admission, or to which the client was exposed on an outing, during treatment at a different facility or office, or while on a pass/leave of absence, including those infections that are chronic, recurrent, or the result of noncompliance with medical therapy.
Facility Acquired/HAI any infection or infestation, preventable or nonpreventable, that occurs because of facility-related care delivery while a client (also referred to as resident or inmate) is in the care of the facility
Special considerations; infection that occurs after admission to the facility and as a result of client injury by a peer or self-injury

27. Unique Characteristics of Behavioral Health
Fewer comorbidities
Increased incidence of HIV, HepB, HepC and TB
Rarely have indwelling devices
They are typically ambulatory
Comingle freely on many wards
Alcohol hand rub -limited because of concerns about ingestion of alcohol by patients with a history of substance abuse
Some similarities between the long-term care residential environment and the psychiatry care environment:
both groups of residents tend to stay for long periods of time,
they attend congregate events
such as group or recreational therapy
Community showers and restrooms
Common dining room

28. Scenario
Problem
A client with varicella, or a recent exposure to varicella, without prior disease or vaccination, is scheduled for admission for medication evaluation.
Solution
This admission should be delayed until the incubation period has passed or the disease has reached a point in illness resolution at which transmission is not a risk. It is important to consider that the client may be infectious 48 hours prior to onset of symptoms. The nonimmune, exposed client may be given varicella vaccine and possibly varicella-zoster immune globulin.

29. Scenario
The same client from Scenario I (a) is already in the facility and develops varicella.
Solution
Initiate Airborne Precautions by placing the client in a negative pressure room and Contact Precautions. In the absence of a negative pressure room, and in situations in which the client cannot be transferred to a facility with appropriate isolation precautions or be safely discharged, initiate other protective measures that are available. If the facility has a HEPA unit, place it in the client’s room. Attempt to have the client stay in his or her room during the infectious state. Identify susceptible staff and clients. The administration of varicella-zoster immune globulin for susceptible individuals should be considered if they meet the criteria. Following CDC recommendations for occupational health, all healthcare personnel should have been screened for a history of varicella. Staff with an unknown history should have titers drawn upon employment, and those with a negative or unknown history should be immunized or offered immunization. Susceptible individuals should be considered to be infectious for 10 to 21 days after exposure. Staff members who refuse vaccination or who are unable to be vaccinated should be furloughed during this period. The administration of varicella-zoster immune globulin prolongs this period to 28 days.
Contact Precautions are applied when the client is in his or her room and the client environment is considered as an extension of the client. When an employee enters the client’s room, Contact Precautions should be enforced (some clients deliberately contaminate the environment); when the client lies down on his or her bed, otherwise clean clothing becomes contaminated. If the client needs to come out of the room, have him or her wear a clean gown covering clothing and nonscabbed lesions and a face mask. Minimize the client’s ability to come into contact with other nonimmune clients to the extent possible. If contact is unavoidable, mask clients who are susceptible (when possible), attempt to maintain a distance of 3 feet or more between clients, and prevent physical contact.

30. Scenario
Problem
A medical hospital wants to transfer a client who has been medically cleared from an overdose. While at the medical hospital, the client was identified to have vancomycin-resistant Enterococcus in his or her stool. The client is incontinent of urine and feces and also smears feces. Because of the client’s psychotic state, he or she is unable to follow directions. What infection exposure risk will this client pose on the milieu?
Solution
This client is a risk to the other clients in the facility but should not, and in many areas cannot, be refused admission based only on current infectious disease status. This client will require one-on-one care for constant redirection. Can adequate staffing be provided? Will the client share a bath with other residents? Is a private room with private bathroom available for this client? If a bed can be blocked, but a private bathroom is not available, this client should not be admitted.
The situation poses an ethical dilemma. The client is not yet a client of the facility, and there are many clients entrusted to the facility’s care who may be placed at risk if adequate housing and staff cannot be provided to care for the transfer. The client’s psychological needs also must be met. If the facility is a psychiatric freestanding hospital or a psychiatric unit within a medical hospital, admit this client. Before the client’s admission, address the staffing and room requirement needs.