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Understanding Federal Tag 441: Infection Prevention and Control
Course Objectives
There are several objectives for this continuing education course.
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Review recent updates to F441
Understand the three different aspects of F441 and the critical role of surveillance and
corrective actions in preventing and controlling infectious outbreaks
Identify the cycle of infection and steps that can be taken to prevent common viral and
bacterial infections
Review a comprehensive set of guidelines to assist with F441 compliance
F441
CMS recently updated its regulations and surveyor guidance for Infection Prevention & Control under
Federal Tag 441. The new F441 combines five federal tags into one comprehensive regulation that
went into effect September 30, 2009 and which CMS has revised several times since.i
The intent of F441 is to assure that nursing homes develop, implement and maintain Infection
Prevention and Control Programs. The goal of these programs is to prevent and control the onset of
infections through active surveillance and sanitary practices across all the departments in the nursing
home.
Surveyors are now taking a proactive approach to investigating whether facilities have an effective
infection prevention and control program, and with every survey will review the facility’s policy and
procedures related to F441.
Increasing Infection Rates
The changes to F441 are the result of increasing infection rates in US nursing homes, many of which
CMS believes are avoidable if proper infection and control best practices were rigorously applied.
Infections account for up to half of all nursing home resident transfers to the hospital and cost between
$670 million to $2 billion to treat each year. When a resident is hospitalized with a primary diagnosis of
infection, the mortality rate can reach as high as 40 percent. The top three infections to nursing home
residents are urinary tract, respiratory and skin/soft tissue infections. ii
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Infection Control Guidelines
The new F441 tag contains three main parts all focused on providing a safe, sanitary and comfortable
environment for nursing home residents, staff and visitors and focuses on preventing the development
and transmission of disease and infection.
The first part requires nursing homes to establish an Infection Control Program. An effective program is
defined as one that investigates and controls in the facility, develops procedures, like isolation, and
maintains records of incidents and the corrective actions that were taken related to infections.
The second part F441 focuses on Preventing the Spread of Infection. This includes isolating residents
to prevent infection, prohibiting employees with communicable diseases for direct contact with
residents or their food, and requiring hand washing after each direct residents contact for which hand
washing is required by standard professional practices.
And lastly, F441 requires nursing homes to handle, store, process and transport linens to prevent the
spread of infection.iii
Infection Preventionist
CMS recommends but does not require that nursing homes appoint an Infection Preventionist to
oversee their efforts. This individual’s job is to lead prevention efforts within the facility, to protect
residents, staff and visitors from infection and communicable disease, to implement infection
prevention and control policy and procedures, and to ensure that the nursing home complies with state
and federal regulations.
The Infection Preventionist also performs surveillance and investigations, prevents and controls
outbreaks, improves processes and outcomes by taking corrective actions and implementing hand
hygiene and linen handling practices to minimize contamination and cross contamination. Surveillance
is particularly important for prevention efforts.
Additionally, the Infection Preventionist decides what procedures to put in place when infections do
arise, such as isolating a resident.
Faced with a potential outbreak of a communicable disease, facilities may need to occasionally isolate
infected residents to reduce transmission of the infection.
When it comes to isolation, CMS recommends taking the least restrictive, but adequate, approach to
protect staff, visitors and other residents, as well as the resident with the infection.iv A least restrictive
approach means maintaining isolation precautions for no longer than necessary. The concern here is
that isolation extended periods may adversely affect a resident’s psychosocial well-being.
•
Airborne precautions require a private room until the resident can be transferred to a hospital.
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Discontinue Contact Precautions after signs and symptoms of infection have resolved
The Infection Preventionist also ensures that hand hygiene is performed before and after staff
members enter isolation settings and that personal protective equipment, like gowns, gloves and
masks, are available and appropriately used.
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Breaking the Cycle of Infection
Overall, infection prevention and control is aimed at breaking the cycle of infection by putting proper
best practices in place, like hand hygiene, cleaning and disinfection procedures, isolation precautions,
active surveillance and corrective
measures.
Susceptible Host
Portal of Entry Mode of Transmission
Let’s examine more closely what
this cycle looks like and the six
critical elements that play a part in
the cycle of infection. (See Figure
1)
Infectious Agent
Reservoir
Infectious Agent
The infection cycle starts with an
infectious agent like a virus or
bacteria. Hepatitis B and C and
HIV are examples of viral
pathogens. Clostridium difficile –
or c. diff-- and Methicillin-resistant
Staphylococcus aureus or MRSA
are two different examples of
bacterial infectious agents.
Portal of Exit
Figure 1 Infection Cycle Figure 2 Infection Reservoirs
Toilet Seat
Door Knob
Animals Colon
•Salmonella
•Shigella
•E. Coli
•C. Diff
Infection Reservoir
The second part of the cycle is the
reservoir where the infectious
agent lives. Common reservoirs
where infectious agents exist can
be inanimate objects like a toilet
seat, bedside table or a door
knob, or an animate reservoir, like
an animal or the human body,
particularly inside the colon. (See
Figure 2) The colon, for example,
acts as a reservoir for many
potentially pathogenic infectious
agents –like salmonella, shigella,
Escherichia coli or E. coli and
c.diff.
Portal of Exit
The third part of the cycle is the
portal of exit or the means by
which the infectious agent leaves
the reservoir. Many infectious
agents exist in a benign state in their reservoir or living environment, and don’t become hazardous until
they escape from the reservoir. Bacterial and viral pathogens can exit through feces, saliva, tears,
blood, mucous discharge, draining wounds and sexual secretions. For example, a syringe can act as a
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percutaneous portal of exit for blood borne pathogens like Hepatitis and HIV.
Mode of Transmission
The next part of the infectious cycle, and one of the most important from an infection control
standpoint, is the means by which the infectious agent is transmitted. Infections take place when a
pathogen is transmitted to another reservoir or host environment where it can live and reproduce.
Transmission can happen through a number of different means—direct and indirect.
Direct contact with the human, animal or environmental reservoir is considered a direct mode of
transmission. This can take place through physical, person-to-person contact or through contact with
bodily secretions, through contact with soil or through breathing droplets which carry airborne
pathogens.
Pathogens can also be transmitted through indirect contact with contaminated reservoirs—like food,
insects, feces, medical equipment and instruments. Infectious agents can also be transmitted through
the bite of an insect carrying the pathogen.
Portal of Entry
The next step in the infection cycle is the portal of entry—which is the way or means that an infectious
agent enters the body. There are different ways that these pathogens enter the body, for example
through:
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Breaks in the skin
Mucous membranes
Digestive tract
Genitourinary tract
And the circulatory system
Susceptible Host
But to gain entry, an infectious agent needs a susceptible host, or an individual who can contract the
disease. Luckily, the body has its own defense systems – such as acquired immunity to infectious
agents, the protective barrier of the skin and certain excretions and enzymes. When the immune
system and other bodily defense systems are functioning at their best, people are able to ward off any
number of diseases. Still, there are many cases when we, as humans, become susceptible to disease
because our defense systems have been weakened. The most susceptible hosts are typically those with
weakened immune systems due to existing conditions or disease, like young children and senior
citizens.
Pathogens
Let’s examine two different types of pathogens— bacterial and viral—and how these pathogens are
currently manifesting in nursing home environments.
Hepatitis B and C and HIV are all viral infections. Viral infections are caused by a virus, which is
microscopic—smaller than bacteria in fact—but encapsulated in a protective coating which makes the
virus more difficult to kill. Viral infections cause illnesses as minor as the common cold and a severe as
Acquired Immuno Deficiency Syndrome or AIDs. While antibiotics do not kill viral infections, there are
many vaccines for the diseases caused by a virus, such as polio or chicken pox. The HBV virus is
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transmitted by bodily fluids, namely blood in nursing homes, but it can also be transmitted through
semen or vaginal secretions that come into contact with mucous membranes.
Polio or poliomyelitis is an example of a viral infection which is spread from person to person typically
by viral agents in fecal matter, which are transmitted by person to person. When the virus enters the
central nervous system it can destroy motor neurons, causing severe muscle damage, weakness and
even paralysis. Fortunately, polio has been nearly eradicated through the polio vaccine.
Hepatitis B Infection Cycle
Here’s an example of how HBV could be transmitted in nursing home environment. The HBV virus is
present in the human body and exits through the blood of the host. Residual contaminated blood may
then remain on an environmental or device. It’s possible that blood from a finger prick could land on a
shared glucose meter. If this device where used again, without proper cleaning and disinfection, the
hepatitis B virus could be transmitted directly from the device or an unwashed hand. After entering a
susceptible resident through mucous membrane the HBV complete the infectious cycle.
Figure 3 Glucose Monitor
Fatal HBV Outbreaks
Blood-borne pathogen outbreaks are very rare, and but the CDC
has documented several cases of long-term care residents
becoming fatally infected with HBV in recent years. In its
investigations, the CDC attributed the outbreaks to contaminated
environmental surfaces and inadequately disinfected equipment,
like glucose monitors. v
F441 covers a wide range of issues, aimed at helping nursing
homes prevent the spread of infection and limit the impact of an
outbreak, if it should occur, and reduce the chance of cross
contamination from blood borne pathogens like HBV.
The recently updated 441 federal tag specifically includes the cleaning and disinfection of Resident-care
devices like electronic thermometers or glucose monitoring devices. Surveyors are proactively
investigating compliance and instructed to observe the cleaning and disinfection of equipment during
annual state surveyors. This includes the cleaning and disinfection of small non-disposable equipment,
like glucose meters, scissors or thermometers. Surveyors are also instructed to observe the disposable
of single-use items after one use, like blood glucose lancets and sharps.
Bacterial Pathogen = Clostridium Difficile
Now let’s examine a bacterial infectious agent. Clostridium Difficile is a gram positive, rod shaped spore
forming bacteria. It exists benignly in the colon. However, antibiotics disrupt the balance, and cause
gastrointestinal programs for those infected. Unlike a virus, bacteria can be killed with antibiotics but
some bacteria have become resistant to numerous types of antibiotics making it more difficult to deal
with and cure infections.
Growing C. Diff Infections
C. Diff is the most common cause of healthcare-associated infectious diarrhea in healthcare facilities.
The elderly or people receiving antibiotics are more likely to develop a CDI. CDI accounts for more than
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40 percent of all gastrointestinal infections in nursing homes and the number of C. diff infections
doubled between 2001 and 2005.vi
C. difficile can survive in a nursing home environment on a resident bed rail, on floors and in or around
toilets in its spore form for up to 6 monthsvii (see Figure 4). Rigorously cleaning the environment
removes C. difficile spores, and can help prevent transmission of the organism. CMS recommends
cleaning equipment used for residents with C. difficile with a 1:10 dilution of sodium hypochlorite (10
parts water to one part bleach) to reduce the
spread of the organism. Once mixed, the
Figure 4 C.Difficile Surfaces solution is effective for 24 hours.
Bed Rails Floors
Toilet Seats Prevent CDI by washing your hands with soap
and warm water. Residents in nursing homes
should wash their hands very often and try to
avoid touching surfaces, especially in
bathrooms. Health care works should always
clean hands before and after caring for a
patient or resident. Nursing home visitors
should wash hands to help prevent infections
from spreading. Clean equipment and
problem areas thoroughly. The Society for
Healthcare Epidemiology of America
guidelines related to C. difficile are acceptable
as they meet CMS requirements and more.
Cleaning & Disinfection Checklist
Let’s review some tips for cleaning and
disinfecting shared medical equipment.
Ideally, the nursing home’s Infection Preventionist should lead this activity.
First, make a comprehensive list of every piece of shared medical equipment in the facility. This list
should include glucose monitors, vital signs monitors or portable international normalization ratio
monitors. Enlist the help of assistant of clinical staff members to help identify and generate a
comprehensive list of all the shared medical equipment in the facility.
Assign the cleaning and disinfection responsibility for each type of medical equipment to the healthcare
worker who will be performing the task within your policy. Make sure to familiarize yourself with the
manufacturer’s cleaning instructions.
Next, select an easy-to-use Environmental Protection agency-registered disinfectant and cleaning
product with the equivalent of 1:10 bleach solution, which is recommended by the CDC in a liquid or
pre-moistened wipe. You should also familiarize and train your staff in the specific disinfectant solution
that your facility uses. Different solutions may require different application techniques. Simply wiping
equipment may not ensure disinfection. Some solutions may need to remain on the equipment for a
specific length of time or other instructions to function properly. Alcohol is not an approved product for
cleaning environmental areas or devices potentially contaminated with blood borne pathogens.
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Educate and train staff on the proper care, maintenance, cleaning and storage of each piece of
equipment. Communicate and train all members of your staff both written and verbally. Once you’ve
trained your staff in your facility’s policies and procedures, document that the training has occurred.
At a minimum, provide this education when the employee starts, when existing equipment is replaced
with a newer model and on an annual basis. Facilities should document that any additional training has
occurred.
Clean, then Disinfect
In addition to the regular cleaning schedule, clean medical device surfaces whenever visible blood or
bloody fluids are present by wiping with a dampened cloth with soap and water to remove any visible
organic material. Once the device has been cleaned, disinfect it with a 1:10 bleach solution.
If no visible organic material is present, disinfect the exterior surfaces after each use using a cloth or
wipe with an EPA-registered detergent or germicide with a tuberculocidal or HBV/HIV label claim or
dilute with a bleach solution with a 1:10 concentration. The EPA maintains a list of all the vendors with
approved Tuberculocide solutions.
Alcohol is not an EPA-registered disinfectant or effective against HBV, HVC and Human
Immunodeficiency Virus (HIV). All cleaning should be done in a well-ventilated area with gloves to
protect the health of employee.
HBV present in blood can withstand drying on a surface for at least a week.
Diabetes Care Precautions
Additionally, never reuse needles, syringes, or lancets. Because of possible inadvertent contamination,
unused supplies and medications taken to a patient’s bedside during finger-stick monitoring or insulin
administration should not be used for another patient. Do not carry supplies and medications in
pockets.
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Restrict use of finger-stick capillary blood sampling devices to individual patients.
Consider using single-use lancets that permanently retract upon puncture.
Dispose of used finger-stick devices and lancets at the point of use in approved sharps
containers.
Assign separate glucometers to individual patients. If glucometers are shared, the device must
be cleaned and disinfected between each patient use.
Whenever possible the CDC recommends using single-dose insulin vials and restricting multi-does vials
to a single resident to reduce the risk of disease transmission. If multiple dose vials are used, they
should be stored and disposed of based on manufacturers recommendations. And healthcare workers
should always follow safe injection practices using standard precautions.
Communicable Disease Prohibition
Facilities must also maintain procedures for how to handle staff with communicable infections or open
skin lesions. Employees with a communicable disease or infected skin lesions should not have direct
contact with residents or their food, if direct contact has the possibility of transmitting the disease.
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During different aspects of state surveys, surveyors will observe staff who exhibit suspicious and
potentially contagious symptoms, including coughing, sneezing or vomiting.
Glove Usage
Facilities must require staff to wash their hands after each direct resident contact for which hand
washing is indicated by accepted professional practice.
Surveyors will:
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Determine if proper hand washing techniques are followed by the staff after contact with
residents
Observe if gloves are worn when there is contact with blood, specimens, tissue, body fluids
and/or excretions
Observe if gloves are changed between resident contacts
Double gloving for the purpose of taking one off after completing one resident treatment and then
moving to the next resident without hand washing and applying new gloves is not allowed. Hand
washing is required between every resident care activity. Staff should also remove gloves and clean
their hands before moving on to another treatment if the treat area is greater than the first.
Hand Hygiene
CMS recommends wetting hands first with warm running water, applying the proper amount of soap
Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers
and under finger nails. Rinse hands with water and dry hands with a disposable towel. Use the
disposable towel to turn off the faucet.
Hand hygiene is required before every resident contact. Soap and water must be used for all kitchen
services. But it is acceptable to use an alcohol-based hand rub between residents when hands are not
visibly soiled.
Infections are Preventable
The overall financial burden incurred by healthcare-associated infections is growing. As noted earlier,
infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost
of between $670 million to $2 billion annually.viii And when a nursing home resident is hospitalized with
a primary diagnosis of infection, the death rate can reach as high as 40 percent.
Experts estimate that approximately one-third of all healthcare-associated infections can be prevented.
Hand hygiene is one of the most important infection-prevention measures and has a proven positive
influence on infection rates. Unfortunately, hand hygiene compliance rates are poor with an estimated
average of about 50 percent.
Germ Theory
Born in Budapest, Hungary in 1818, Dr. Ignaz Semmelweis discovered that the incident of puerperal
fever – or childbed fever – could be drastically reduced by using hand disinfection techniques. Childbed
fever was common in hospitals in the mid-1880s and often fatal with a mortality rate of up to 35
percent.
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Semmelweis made the connection between higher incidents of the childbed fever and mortality in the
wards at Vienna General Hospital than amongst midwives. He postulated that invisible germs were
picked up from the body of cadavers and were then transmitted to patients at the hospitals obstetrical
clinics.
He postulated that performing hand disinfection -- by washing the hands in a chlorinated lime solution
-- could reduce mortality rates to below 1 percent. A radical idea at the time, Dr. Semmelweis’ theory
was discredited, only to be accepted later by the academic and medial communities.
Microorganisms
Microorganisms are everywhere. The fact that they are not visible to the naked eye makes dealing with
them difficult. Even though we might not be able to see them, germs are constantly on our skin. These
germs don’t pose much of a problem in everyday life, but they do become problematic in healthcare
settings.
In healthcare settings like nursing homes and hospitals, healthcare personnel deal with people lacking
fully effective immune systems. Hand hygiene in healthcare settings is about protecting people –
patients, nursing home staff and visitors – against possibly pathogenic organisms with the potential to
cause dangerous infections.
There are several possible transmission paths for healthcare-associated infections: by direct or indirect
contact, by contaminated objects, and in rare instances, airborne pathogens can be transmitted
through the air. It is generally agreed that most infections in healthcare settings are transmitted by
contact. Therefore great importance must be paid to hand hygiene.
Chain of Transmission
According to Dr. William Jarvis of the Centers for Disease Control, “Infections are most often
transmitted from patient to patient on the hand of healthcare workers.”
Figure 5 Chain of Transmission Healthcare Personnel Contaminated Surface
Resident
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Hands are the main transmitters of healthcare-associated infections, followed by work clothing and
other inanimate objects. This isn’t surprising since the hands of healthcare workers are constantly in
contact with their surroundings – not only when caring for residents and patients – but also when
performing other necessary activities such as opening a door, touching a computer keyboard or dialing
a phone (See Figure 5). Bacteria, fungi and viruses, which only transiently colonize on the skin, are
easily taken up and passed on, either through direct contact – from the skin to the skin – or through
indirect contact – from surfaces, objects, equipment and shared medical devices.
Contaminated Surfaces
One particularly prevalent chain of transmission in healthcare settings is from a contaminated
inanimate surface to the healthcare worker to the patient or nursing home resident. The chain of
transmissions also flows in the opposite direction.
Many pathogens can persist on inanimate surfaces for several months. As noted earlier c. diff can
survive in an environment, like floors, bed rails or around toilet seats in its spore form for up to six
months.ix Numerous other pathogens are even more persistent than c.diff. E.coli can persist for up to
16 months on an inanimate surface and staphylococcus aureus strains like MRSA can persist for up to
16 months as well.x
It is important that healthcare personnel are aware of the permanent presence of possibly pathogenic
organisms and the special situations in which they are working.
No Infections on Hands
Pathogens of existing infections on the hands—like abscesses, superlative inflammations on the finger
or nail bed or infected eczema—cannot be killed or reduced.
A nursing home can rule out infected hands as a dangerous source for infections by not allowing staff
with infections on the hands from performing direct resident care until they are healed.
F441 specifically requires that nursing home facilities must prohibit employees with a communicable
disease or infected skin lesions from direct contact with residents or their food—if direct contact will
transmit the disease.xi
F441 also requires that this prohibition be reflected in the facility’s Infection Prevention and Control
policies and procedures, and that the facility maintain documentation of how they handle staff with
communicable infections or open skin lesions.
Artificial Nails
Whether artificial nails contribute to the transmission of healthcare-associated infections has not been
determined.xii However, healthcare personnel who wear artificial nails are more likely to harbor
pathogens on their fingertips than those with natural nails – both before and after hand washing.
The CDC recommends that healthcare workers do not wear artificial fingernails or tips when having
direct contact with high-risk patients or residents. An example of a high-risk nursing home resident
would be one in isolation for an infection or, in the hospital setting, a patient in an intensive care unit.
The CDC also recommends that healthcare workers keep natural nail tips less than one quarter of an
inch long. The World Health Organization also recommends that healthcare workers should not wear
artificial nails or tips and recommends that healthcare workers keep natural nails short.xiii
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Figure 6 Areas of Greatest Microorganism Density
Microorganism Density
When performing hand antisepsis, keep in
mind the places where microorganisms tend
to dwell.
Let’s examine the image to the left (Figure
6). It depicts the results of a studyxiv on the
composition and density of microflora on the
hands. Over 61,000 microorganisms per
square centimeter were found under the
fingernails, while only 847 were found per
square centimeter on the palms. That means
that 72 times more microorganisms or
colony-forming units were found under the
fingernails than on the palms of the hands.
Ranked from greatest to least, the microorganism density is greatest under fingernails, followed by the
palms, backs of hands, between fingers and on the top of finger nails. Healthcare workers should make
sure that they perform thorough antisepsis that includes all of these areas and the entire hand.
Three Elements of Hand Hygiene
There are three important components to effective hand hygiene. Hand washing, hand antisepsis (or
hand disinfection) and skin care.
Figure 7 Normal vs. Cracked Skin
Normal, Healthy Skin Cracked Skin
Hand washing includes cleansing hands when they are visibly
soiled with plain soap and water.
There are two types of hand antisepsis used to disinfect the
hands. One involves washing hands with an alcohol-based
product that stays on or isn’t rinsed from the hands. The
other type of hand antisepsis involves washing the hands
with water and an antimicrobial soap or other detergents that
contain antiseptic agents.
The last component is Skin Care, which is comprised of two
components—the prevention of skin-stressing activities and
the use of healthcare approved skin creams or lotions to
moisturize and protect the skin.
Hand Washing
Let’s look into the first of the three components of effective
hand hygiene. In healthcare, washing hands with water and
plain soap is done to remove visible soils. In accordance with
CDC hand hygiene guidelines, the average clinical situation
does not call for hand washing with soap and water. Thus,
while acceptable, the use of soap and water should be kept
to a minimum.xv
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Frequent and prolonged hand washing attacks the skin’s protective acid mantle and skin lipids are
washed off the skin. Hand washing destroys the protective function of the stratum corneum or the
surface layer of the skin– which causes natural skin oils to be dissolved and washed off. This has been
proven to lead to skin irritations and contact dermatitis in some instances because these natural oils
and lips, which our naturally resident in our skin and which perform a protective function, help keep
the skin in a good condition.
Healthy vs. Cracked Skin
Let’s look at the difference between normal healthy skin and dry, cracked skin. Examine the top
picture. It depicts what normal, healthy skin looks like under a microscope. Compare this image with
the lower picture, which depicts cracked, dry and scaly skin (See Figure 7).
You will notice the large number of cracks and fissures in the lower picture. The number of fissures and
cracks, which are typical of hands in a distressed state, are much more visible in the lower picture.
When we have cracked, dry and scaly skin, pathogens and microorganism can find these cracks but
many antiseptics cannot reach these pathogens.
Hand Disinfection
Today, a majority of clinical situations across healthcare settings call for hand disinfection and not hand
washing. In principle, hand antisepsis refers to reducing the number of viable microorganisms on the
hands. It is the most important measure for protecting patients and personnel against healthcareacquired pathogens.
In patient care, there are many situations in which hand antisepsis is essential. Germs, which only
temporarily colonize the skin, are easily passed through direct or indirect contact. These
microorganisms belong to transient skin flora, which includes gram-negative bacteria, aerobic spore
formers, fungi and virus. These microorganisms are often pathogenic and are mostly the elicitors of
infections.
The transient skin flora can be reduced relatively easy by properly performed hand antisepsis, which
aims to destroy transient skin flora.
Hand Antisepsis & Germ Kill Rates
There are two types of hand antisepsis: Alcohol-based hand rubs and antiseptic hand wash with water
and antimicrobial soap or other detergents that contain an antiseptic agent. The best option to use is
an alcohol-based rub-in product because they have the fastest and broadest antimicrobial efficacy
according to the evidence base and reinforced by the CDC and WHO. Additionally, well-formulated
alcohol-based hand rubs contain skin emollients which support the protective function of the skin.
Bactericidal rates or germ kill rates vary based on the type and concentration of antimicrobial agents
used in alcohol-based hand rubs. Antiseptic hand rubs with ethanol or isopropanol – which are all
different types of alcohol – have been found to have the strongest kill rates.
Ethanol is more widely used than isopropanol in hand sanitizers because this type of alcohol has been
proven to have a slighter higher germ kill rate.xvi
Antiseptic hand wash with triclosan and chlorhexidine gluconate have been found to have lower kill
rates than alcohol. And hand washing with non-medicated soap has the lowest kill rate.
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CDC Guidelines
In 2002, the CDC published its guidelines for hand hygiene. It recommends the use of alcohol-based
hand rubs for the routine decontamination of hands if the hands are not visibly soiled. The CDC also
recommends that when alcohol-based hand sanitizers are used, they should contain between 60 to
95% alcohol because they have been proven to be most effective.xvii
Additionally, using alcohol-based rubs can save time. They have been proven to be more effective if
properly used. And increasingly, alcohol-based hand rubs are becoming the standard of care.
When hands are visibly soiled, however, the CDC recommends the use of hand washing. This includes
instances when the hands are visibly dirty, contaminated with proteinaceous material or are visibly
soiled with blood or other bodily fluids.
Also, alcohol does not kill the spore form of c.diff. If you suspect that you have a c.diff resident, it is
always best to use soap and water because the physical action of rubbing the hands and creating
friction helps to wash the bacteria down the drain as opposed to actually killing the spore.
Skin Care
The third and final piece of the three elements of hand hygiene is skin care. In skin care, we are trying
to avoid and prevent skin stressing activities and use hand lotions. In normal cases, the skin’s defense
mechanisms are adequate. But when skin-stressing habits are continued, the skin’s defenses might
become exhausted over time.
Some of the key skin stressing factors include prolonged hand washing with soap and water, brushing
or scrubbing, prolonged wearing of gloves and contact with irritant substances.
One measure to assist in maintaining a natural barrier to protect the skin is the use of skin care
products like creams or lotions that are approved for healthcare use.
Hand Hygiene
Hand hygiene is a critical defense against healthcare associated infections. Yet, there are several major
challenges to better hand hygiene practices in healthcare settings, such as lack of education, lack of
awareness about the importance of hand hygiene in preventing infections and cross contamination and
behavior challenges, as frequent hand washing often irritates skin. Nursing homes must require staff to
wash their hands after each direct resident contact for which hand washing is indicated by accepted
professional practice. The following list includes some, but not all, of the instances when proper hand
washing is required:
–
–
–
–
–
–
–
–
–
–
At the start and end of duty
Before and after direct resident contact
Before and after performing an invasive procedure
Before and after eating or handling food
Before and after the insertion of indwelling catheters
Before and after wound dressing changes
After personal use of the toilet
After blowing or wiping nose
After handling soiled or used linens, dressings, bedpans, catheters and urinals
After handling soiled equipment or utensilsxviii
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Linen Handling
Infection control and prevention best practices extend to hand hygiene practices and processes to
properly store, handle, process and transport potentially contaminated linens.
CMS requires that linens “must be handled in a manner so as to prevent transmission of infectious
agents.”
Most homes treat all linens as potentially contaminated. When this is the case, no additional separating
or labeling of linens is required to stay in compliance with F441. However, if staff does not treat all
linens as potentially contaminated, then additional precautions, such as labeling or color-coding linens,
are needed to separate potentially contaminated linens from the rest of the batch.
Laundering
Ensure that linens are cleaned and disinfected to minimize the likelihood of transmitting infection.
Maintain equipment according to manufacturer instructions. Use an Environmental Protection Agencyapproved (EPA) germicidal detergent on all linens between residents. When washing linens ensure
that:


Water temperatures are above 160° Fahrenheit for at least 25 minutes, or
Water temperatures are between 71 and 77° Fahrenheit with 125 part-per-million chlorine
bleach rinse.
Current guidelines do not allow for the adjustment of washing temperatures using ozone.
Linen Handling
Store, handle, process and transport linens to minimize contamination, which means practicing proper
hand hygiene when handling and processing soiled or used linens, dressings, bedpans, catheters and
urinals. Additional guidelines for compliance include:





Ensuring that laundry areas have hand washing facilities
Using moisture resistant mattress covers
Laundering fabric mattresses covers between residents
Making personal protective equipment available
Utilizing proper detergent and water temperatures to kill germs
Additionally, never hug contaminated linens, which can cause infectious agents to transfer to the
uniform or clothing.
Surveyor Guidance
Surveyors will observe various departments, as well as staff, residents and family members during
annual surveys to determine:




If
If
If
If
staff and visitors adhere to precautions
precautions are in place
residents exhibit signs and symptoms of infections
cleaning and disinfection takes place as required
Page 14 of 16 www.medlineuniversity.com Understanding Federal Tag 441: Infection Prevention and Control
Surveyor Checklist
Observation for the proper disposal of equipment is another important aspect of determining
compliance with F441. Surveyors will observe the handling of different types of items (see Figure 8) ,
such as:
Figure 8 Compliance Checklist Small non‐
disposable equipment
• Glucose meters
• Scissors • Thermo‐
meters
Single Resident Use Items
• Basins
• Bed pans
Resident Dressings
Multiple Use • Proper Storage • Soiled dressings discarded
• Shower chairs
• Bedside scales
• Resident lifts Disposable of single‐
use items
• Blood glucose lancets
• Sharps • Syringes
Surveyor Guidance
To determine compliance, expect surveyors to conduct resident Interviews to assess whether residents
understand infection control best practices through education from the facility on things like hand
hygiene, special precautions and whether their family members also understand the importance of
these actions.
In Staff Interviews surveyors will ask about hand hygiene practices and transmission-based
precautions. Surveyors will also conduct a Record Review to see how the facility addresses Infection
risks for medical interventions like indwelling catheter or tracheotomy tubes.
They will review the facility’s Infection Control Policy with particular interest in data collection and
analysis activities. Lastly, surveys will observe how linens are handled, processed and stored.
i
F441 §485.65 Infection Control, CMS Manual System, Publication 100-07 State Operations Provider Certification, Department of Health &
Human Services, Centers for Medicare & Medicaid Services, Transmittal 55: December 2, 2009.
ii
Ipid, p.7.
iii
Ipid, p. 3.
iv
Ipid, p. 17.
v
Transmission of Hepatitis B Virus Among Persons Undergoing Blood Glucose Monitoring
in Long-Term--Care Facilities --- Mississippi, North Carolina, and Los Angeles County, California, 2003—2004, Morbidity and Mortality Weekly
Report, Centers for Disease Control, March 11, 2005 / 54(09); 220-223.
vi
Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2008.
vii
F441,Transmittal 55, p. 1.
viii
Ipid, p.7.
Page 15 of 16 www.medlineuniversity.com Understanding Federal Tag 441: Infection Prevention and Control
ix
Ipid, p. 1.
Kramer A, Schwebke I, Kampf g. How long do nosocomial pathogens persist on inanimate surfaces?: A systematic review. BMC Infect Dis.
2006; 6:130.
xi
F441, Transmittal 55, p. 3.
xii
Boyce JM, Pittet D. Centers for Disease Control and Prevention, Guideline for Hand Hygiene in Health-Care Settings. Recommendations of
the Healthcare Infection Control Practices, Advisory Committee and HPICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51:145.
xiii
World Alliance for Patient Safety. Who Guidelines in Hand Hygiene in Health Care (Advanced Draft), Global Patient Safety Challenge 20052006: “Clean Care is Safer Care.” April 2006.
xiv
McGinley KJ, Larson El, Leyden JJ. Composition and density of microflora in the subungual space of the hand. J Clin Microbiol. 1988; 26(5):
950-953.
xv
Commission for Hospital Hygiene and Infectious Disease Prevention of the Robert Koch Institute. Hand Hygiene. Bundesgesundheitsbl –
Gesundheitsforsch – Gesundheitsschutz. 2000; 43:230-233.
xvi
Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin
Microbiol Rev. 2004; 17:863-893.
xvii
Boyce JM, Pittet D: Guideline for Hand Hygiene in Health-Care
xviii
F441, Transmittal 55, p. 16.
x
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