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Infection Control in Long-Term Care: An Old Problem and New Priority

Published:December 22, 2021DOI:https://doi.org/10.1016/j.jamda.2021.12.010

      Keywords

      The COVID-19 pandemic highlights broken systemic processes within our country’s nursing homes (NHs) with tragic outcomes. Staff are responsible for preventing, identifying, investigating, and controlling infections without the proper training and personnel. Early studies have shown that between 40% and 45% of COVID-19–related deaths have occurred in LTC facilities.
      • Kumar A.
      • Roy I.
      • Karmarkar A.M.
      • et al.
      Shifting US patterns of COVID-19 mortality by race and ethnicity from June-December 2020.
      • Ouslander J.G.
      • Grabowski D.C.
      COVID-19 in nursing homes: calming the perfect storm.
      Morbidity and mortality related to COVID-19 has disproportionately affected older adults residing in LTC facilities.
      • Kumar A.
      • Roy I.
      • Karmarkar A.M.
      • et al.
      Shifting US patterns of COVID-19 mortality by race and ethnicity from June-December 2020.
      • Ouslander J.G.
      • Grabowski D.C.
      COVID-19 in nursing homes: calming the perfect storm.
      Since the implementation of COVID-19 vaccination protocols in December 2020, a sharp decrease in COVID-19 diagnoses and deaths have been observed in the NH population
      • Chidambaram P.
      • Garfield R.
      COVID-19 long-term care deaths and cases are at an all-time low, though a rise in LTC cases in a few states may be cause for concern.
      ; however, ongoing infection control concerns remain. The average NH resident is in their 80s, and these residents face an increased infection risk because of a host of factors including age-related lowered physiologic reserves and weakened immune systems, chronic comorbidities, and congregate housing conditions.
      • Ouslander J.G.
      • Grabowski D.C.
      COVID-19 in nursing homes: calming the perfect storm.

      Current Infection Control Challenges

      Infection control concerns within NHs is not a new phenomenon. Viral infections, most notably influenza and noroviruses, are commonly diagnosed in LTC settings.
      • Ouslander J.G.
      • Grabowski D.C.
      COVID-19 in nursing homes: calming the perfect storm.
      • Jester D.J.
      • Peterson L.J.
      • Dosa D.M.
      • Hyer K.
      Infection control citations in nursing homes: Compliance and geographical variability.
      The Centers for Medicare & Medicaid Services (CMS) implemented a tiered approach for new infection control regulations (§483.80) in November 2016 and include a systematic approach to prevention, identification, investigation, and control of infections. However, the regulations do not stipulate the educational requirements for a nurse or the amount of time dedicated to infection control duties, and full implementation of the new regulation has been repeatedly stalled.
      • Jester D.J.
      • Peterson L.J.
      • Dosa D.M.
      • Hyer K.
      Infection control citations in nursing homes: Compliance and geographical variability.
      ,
      42 Code of Federal Regulations. §483.80. Infection control.

      Geriatric Education

      The COVID-19 death toll of NH residents has ignited a growing demand for ensuring education in geriatric care competencies for all NH staff. There is a crucial need for urgent action to protect and care for older adults in LTC settings. The unique care needs of this vulnerable population have been overwhelmingly demonstrated during the current pandemic. Expertise in care of older adults is developed over time and requires that foundational geriatric knowledge and skills be reinforced and advanced through continuing education and clinical practice. Currently, there is no CMS-mandated geriatric education requirement for licensed practical nurses (LPNs) or registered nurses (RNs) working in NHs.
      US Department of Health and Human Services
      COVID 19 intensifies nursing home workforce challenges.
      The only CMS-mandated training requirement is that certified nursing aides (CNAs) complete a 75-hour training program with a minimum of 16 hours of clinical training, demonstrating basic competencies in infection control, residents’ rights, and basic nursing skills. During the pandemic, staff shortages intensified, prompting CMS to waive the 75-hour CNA training and thereby allowing NHs flexibility in determining the number of hours dedicated to educational content and clinical training.
      Centers for Medicare & Medicaid Services
      Updates to long-term care (LTC) emergency regulatory waivers issued in response to COVID-19.

      Strategies for Improved Care and Stakeholder Responsibilities

      There are multiple stakeholders that each have responsibilities for improving the current situation in NHs, including CMS, Congress, professional organizations, and NH owners and administrators. In response to the disproportionate number of NH residents contracting and dying from COVID-19, a position statement was developed by the Gerontological Advanced Practice Nurses Association, outlining such concerns, and suggesting actionable recommendations. Addressing Nursing Home Safety During the COVID-19 Pandemic and Beyond recommendations include changes in NHs that support improving infection control practices, such as staffing and education issues, and the amount and quality of education required for all direct care workers employed at LTC facilities.
      Gerontological Advanced Practice Nurses Association
      Addressing nursing home safety during the COVID-19 pandemic and beyond.
      Multifaceted strategies are necessary to achieve evidence-based infection control practices and properly trained staff, requiring financial and time commitments from stakeholders. CMS should be accountable for improving the quality of care provided to NH residents as payor and regulator. Improved consistency in surveyor training is needed to decrease geographic variability in cited care deficiencies.
      • Jester D.J.
      • Peterson L.J.
      • Dosa D.M.
      • Hyer K.
      Infection control citations in nursing homes: Compliance and geographical variability.
      Federal regulations should require adequate staffing ratios based on resident acuity levels calculated from comprehensive assessment data. Higher RN staffing is associated with improved quality measures, such as decreased infection rates.
      42 Code of Federal Regulations. §483.80. Infection control.
      Reimbursement rates from CMS must be increased and earmarked for enhanced staff training, adequate staff-to-resident ratios, and increased pay for direct care staff. Legislation will likely be required to raise reimbursement rates and mandate minimum wage and staffing ratios.

      Next Steps

      Infection prevention and control in NHs is an ongoing problem, brought to new and dangerous light with the outbreak of the COVID-19 pandemic. Crisis is a common motivation for change and now is the time to actively lobby for legislation to protect this vulnerable population. Our collective new priority and responsibility must be enforcement of regulations and policies that enhance infection control and geriatric education, improved reimbursement, and federal mandated staff-to-resident ratios to successfully prevent and manage future infectious disease threats.
      Table 1Recommended Actionable Items for Improving Infection Control Practices
      Infection control preventionist
       • Required Centers for Disease Control and Prevention infection control preventionist training
       • Dedicated job without additional administrative or resident care responsibilities
       • Registered Nurse or Bachelor of Science in Nursing preferred
      Mandated education
       • Required training for all nursing and ancillary staff on the aging process and clinical presentation of infections
       • Required training for all nursing and ancillary staff on basic infection control principles
      Regulatory and reimbursement
       • Minimum staffing ratios linked to comprehensive resident assessment data
       • Enhanced surveyor training and oversight for consistency across all geographic regions
       • Increased reimbursement with mandated infection control preventionist position and staff training allocations
      Nursing homes
       • Up-to-date policies and procedures addressing infection control practices, infection preventionist role, geriatric education, and staffing ratios
       • Regular assessment and professional development to maintain staff’s competencies related to infection control and geriatric care
       • Investment in physical plant updates to enhance the environment for effective infection control practices
      Educational institutions
       • Form partnerships with local nursing homes to assist in providing up-to-date training of nursing home staff

      References

        • Kumar A.
        • Roy I.
        • Karmarkar A.M.
        • et al.
        Shifting US patterns of COVID-19 mortality by race and ethnicity from June-December 2020.
        J Am Med Dir Assoc. 2021; 22: 966-970
        • Ouslander J.G.
        • Grabowski D.C.
        COVID-19 in nursing homes: calming the perfect storm.
        J Am Geriatr Soc. 2020; 68: 2153-2162
        • Chidambaram P.
        • Garfield R.
        COVID-19 long-term care deaths and cases are at an all-time low, though a rise in LTC cases in a few states may be cause for concern.
        • Jester D.J.
        • Peterson L.J.
        • Dosa D.M.
        • Hyer K.
        Infection control citations in nursing homes: Compliance and geographical variability.
        J Am Med Dir Assoc. 2021; 22: 1317-1321
      1. 42 Code of Federal Regulations. §483.80. Infection control.
        (42 CFR 483.80 - Infection control)
        govregs.com
        Date accessed: July 9, 2021
        • US Department of Health and Human Services
        COVID 19 intensifies nursing home workforce challenges.
      2. 42 Code of Federal Regulations. §483.150.
        • Centers for Medicare & Medicaid Services
        Updates to long-term care (LTC) emergency regulatory waivers issued in response to COVID-19.
        • Gerontological Advanced Practice Nurses Association
        Addressing nursing home safety during the COVID-19 pandemic and beyond.