In reviewing the literature, studies of infections in long term care sometimes cite staggering mortality figures like “nearly 400,000 deaths annually.” Is the mortality of infections in long term care really four-fold that of the 100,000 patients who die annually of health care associated infections(HAIs) in hospitals? Or unbelievably enough, could it actually be higher?
A recently published study found that 15% of all U.S. nursing homes receive deficiency citations for infection control per year, with many of those breaches tied to staffing issues.1 In reviewing the historical data, the authors note that “between 1.6 and 3.8 million infections occur each year in these nursing homes, with almost 388,000 deaths attributed to these infections.”2
On further investigation, we find that these numbers reflect extrapolated mortality estimates from data that are now about a decade old. They have been preserved in the literature like amber because there is no national surveillance system for long term care infections — let alone their morbidity and mortality.
One of the studies frequently cited for the death toll was published in 2000, says Nimalie Stone, MD, MS, a medical epidemiologist specializing in long term care at the Centers for Disease Control and Prevention. Moreover, Stone says even that work drew on some studies that date back to the 1980s and 1990s.3
“I would say we don’t have a current estimate of the number of infections and outcomes [in long term care], but we know it is a very vulnerable group of people,” she says. “They have a lot of reasons to have greater risks for infections and worse outcomes, and some of that is driven by the natural waning of the immune system that happens with age.”
As infection prevention in long term care becomes a national priority and the CDC increases surveillance by expanding its existing hospital sentinel system, the toll of infections in long term care may come into better focus. The longstanding perception in hospitals that infections were an inevitable consequence of increasingly invasive care has been shattered by dramatic “zero infections” success stories in recent years. However, the old dogma may still apply in long term care, where as many people may die with infections as do because of them.
It remains an open question how many HAIs in long term care can be prevented, and correspondingly, how much that grim death estimate could be reduced. Given the frequently cited lack of resources in long term care, one would think the increasing national emphasis could yield some dramatic results in nursing homes. On the other hand, the old mortality estimates were certainly based on resident populations with less acuity than those in long term care today. By that logic, the death toll may even be higher than the literature estimates.
1. Castle NG, Wagner LM, Ferguson-Rome J, et al. Nursing home deficiency citations for infection control. Am J Infect Control 2011;39:263-9
2. Richards C. Infections in residents of long term care facilities: an agenda for research report of an expert panel. J Am Geriatr Soc 2002;20:570-576.
3. Strausbaugh LJ, Joseph CL. The burden of infection in long term care. Infect Control Hosp Epidemiol 2000; 21:674-679 n