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Preventing infection in behavioral health settings

Schweon, Steven J. MPH, MSN, RN, CIC, FSHEA, FAPIC

doi: 10.1097/01.NURSE.0000559930.04760.4e
Department: NEW BEHAVIORAL HEALTH
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Steven J. Schweon is an infection prevention consultant in Saylorsburg, Pa.

The author has disclosed no financial relationships related to this article.

APPROXIMATELY ONE IN five adults in the US lives with a mental illness.1 Further, between 20% and 25% of the country's homeless population has some form of mental illness.2 Untreated mental illness can put patients at a higher risk for infection due to risky behaviors, functional impairment, immunodeficiency, and comorbidities.3 Persons with a mental illness may be dual diagnosed, which means having a mental illness coupled with alcohol or drug abuse.4 Those with a triple diagnosis have a mental illness, substance abuse disorder, and HIV infection.5

Patients with a mental illness may be found in various healthcare settings, including acute care hospitals, freestanding psychiatric hospitals, substance abuse centers, outpatient practices, homeless shelters, long-term care facilities, and correctional institutions. This article discusses challenges and nursing interventions associated with infection prevention in patients with behavioral health issues.

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Risk factors

Living with a mental illness may increase an individual's infection risk for many reasons, potentially hindering quality healthcare delivery. (See Raising the risk of infection.) The most common infections affecting patients with a mental illness include infections of the eyes, ears, upper respiratory tract, and skin and soft tissues.2 Further, the behavioral health setting poses several infection risks on its own. Due to its emphasis on independence, group therapy, and social interaction, the risk of transmitting influenza and other respiratory pathogens increases, as does the risk of transmitting pathogens such as methicillin-resistant Staphylococcus aureus that are spread by direct contact.

In addition, patients with impulse control disorders may become violent. This may lead to a physical altercation and biting, which could result in staff or another patient being exposed to bloodborne pathogens. Spitting may transmit pathogens in sputum.6 Sexual encounters may also occur, leading to transmission of sexually transmitted infections (STIs). This patient population is also at a higher risk of contracting tuberculosis, especially in those experiencing homelessness or recently incarcerated.7 Regardless of the practice setting, patients may be engaging in self-harm behaviors that could lead to infection, such as cutting.8

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Assessing risk

The Joint Commission's emphasis on assessing the risk of self-harm has prompted healthcare organizations to require clinicians to perform self-harm risk assessments for patients admitted to behavioral health units.9 This includes ensuring room fixtures such as bathroom sinks and toilets are constructed to prevent self-harm by hanging or drowning. In contrast, in an acute care hospital where these precautions may not be fully implemented, the patient might be placed on one-to-one nursing observation to maintain safety.

Regardless of the clinical setting, a risk assessment must be performed to prevent patient harm. Based on these assessment findings, the nurse should initiate appropriate precautions. For instance, alcohol-based hand sanitizers may need to be kept secured and away from the patient due to the potential for ingestion. Nonalcohol-based hand sanitizers are available as an alternative. Masks and gloves pose a ligature risk and must also be kept secured. Access to sharps containers can potentially lead to syringe and needle theft. Even disinfectant wipes may pose a health risk if ingested. Trash cans should not contain plastic bags due to the suffocation risk; paper bags may be used instead. Toilets may present a drowning risk.

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Transmission-based precautions

The need for isolation precautions varies depending on the practice setting and on whether the individual is colonized or infected with a multidrug-resistant organism (MDRO).10,11 In the behavioral health setting, isolation precautions are patient-centric and may be modified when caring for an independent patient with an MDRO, as well as with other infections.11

In this setting, it may be challenging to ask the patient with a communicable disease such as norovirus to remain in his or her room and adhere to infection prevention precautions. In another example, the use of surgical masks for droplet precautions may increase a patient's paranoia; in addition, clinicians must ensure safe disposal of the mask due to its ligature risk. In contrast, patients with an MDRO or other infection admitted to an acute care hospital may be managed with a more rigid approach to isolation precautions due to the practice setting and patient acuity.11

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Infection prevention

Maintaining environmental hygiene to reduce microbial contamination and promote a safe environment will aid infection prevention efforts. Healthcare facilities should use US Environmental Protection Agency-registered disinfectants or detergents/disinfectants approved for hospitals that best meet the facility's overall needs for routine cleaning and disinfection. These agents must be stored securely to prevent accidental or intentional ingestion. Reusable patient-care items and equipment must be cleaned and disinfected or sterilized between each patient use as appropriate, whenever single-patient use items are unavailable.

The CDC's National Notifiable Diseases Surveillance System assists with public health monitoring, control, and prevention of about 120 diseases, including infectious diseases such as HIV and hepatitis.12,13 However, notifiable conditions may vary from state to state. The local public health department is a credible resource to help nurses determine which infections are reportable in their state.

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Education is key

The nurse should perform an assessment to determine if the patient is capable of understanding and implementing instructions, such as performing hand hygiene and cough etiquette. Wounds should be kept covered and body fluids contained. Patients and their families or caregivers may need ongoing and consistent education on understanding and preventing infection. The CDC is a reliable source for infection information in both English and Spanish. Be sure to document the provided education according to your organization's policy.

Caring for an individual with a behavioral health disorder may be challenging. Healthcare personnel need to have a heightened awareness of each patient's infection susceptibility. Preventing infection is essential, regardless of the practice setting, to ensure safety and optimal patient outcomes.

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Raising the risk of infection

Factors and behaviors that could increase infection risk in a patient with a behavioral health disorder include the following.

  • Patients may have an impaired ability to communicate, which can make it challenging for clinicians to obtain a comprehensive health history when assessing for signs and symptoms of an infection or obtaining an MDRO history.
  • Homelessness can impair a person's ability to perform basic hygiene such as bathing and oral care, which may lead to skin infections and dental decay. Poor hygiene also increases the risk of body lice infestations, leading to trench fever and epidemic typhus.14 Poor dental health can lead to respiratory tract infections such as pneumonia.15
  • Individuals with impulse control disorders may engage in physical, violent episodes that may expose others to bloodborne pathogens. Self-harm behaviors such as cutting may result in skin and other types of infections. Substance abuse is associated with skin infection and bloodborne pathogen exposure.
  • Individuals who are addicted to alcohol or experiencing homelessness are at increased risk for pneumonia and tuberculosis.16,17
  • Approximately 44% of all cigarettes sold in the US are purchased by people with psychiatric disorders. Smoking impairs the immune system and increases infection risk.18
  • Underimmunization increases susceptibility to vaccine-preventable diseases such as influenza.19
  • Impulsivity and/or intoxication from substance abuse increases the risk of STIs.20
  • Advanced age results in declining immune system function, regardless of whether a mental illness is present.
  • Cheeking, the practice of storing an oral medication in the cheek or another part of mouth to evade ingestion, can prevent optimal antibiotic therapy.
  • Malnutrition can impair the immune system.21
  • Patients who have a history of I.V. drug abuse who are receiving I.V. medications to treat an infection may introduce illicit substances into their I.V. access, leading to additional or recurring infections such as bacteremia or integumentary infections.
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REFERENCES

1. National Institute of Mental Health. Mental illness. 2017. http://www.nimh.nih.gov/health/statistics/mental-illness.shtml.
2. National Coalition for the Homeless. Mental illness and homelessness. 2009. http://www.nationalhomeless.org/factsheets/Mental_Illness.pdf.
3. Fedoriw LM. Behavioral health. In: Association for Professionals in Infection Control and Epidemiology. APIC Text of Infection Control and Epidemiology. Arlington, VA: Association of Professionals in Infection Control and Epidemiology; 2014.
4. U.S. National Library of Medicine. MedlinePlus. Dual diagnosis. 2018. https://medlineplus.gov/dualdiagnosis.html.
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6. Centers for Disease Control and Prevention. About Epstein-Barr Virus (EBV). 2018. http://www.cdc.gov/epstein-barr/about-ebv.html.
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11. Siegel JD, Rhinehart E, Jackson M, Chiarello Lthe Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. 2007. http://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf.
12. Centers for Disease Control and Prevention. 2018 national notifiable conditions. wwwn.cdc.gov/nndss/conditions/notifiable/2018/.
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17. Centers for Disease Control and Prevention. TB in the homeless population. 2018. http://www.cdc.gov/tb/topic/populations/homelessness/default.htm.
18. Centers for Disease Control and Prevention. Smoking and overall health. http://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/pdfs/fs_smoking_overall_health_508.pdf.
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21. Katona P, Katona-Apte J. The interaction between nutrition and infection. Clin Infect Dis. 2008;46(10):1582–1588.
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