Nursing home deficiency citations for infection control

Learning from Nursing Home Infection Prevention and Control Citations During the COVID-19 Pandemic

The devastating effects of coronavirus disease 2019 (COVID-19) highlight the critical need for effective infection prevention and control (IPC) practices in nursing homes. Nursing management and infection preventionists should be cognizant of the most common reasons underlying federal IPC citations during the pandemic. Analysis of IPC citation data from the first 7 months of the public health emergency identified that adherence to personal protective equipment (PPE) and mask use, appropriate transmission-based precautions, and hand hygiene were the most common reasons for COVID-19-related F880 citations, including those that placed a person at immediate risk for serious injury or death. More specific staff practices and other factors leading to a citation are also highlighted. Although nursing homes may have limited control over factors such as PPE supply and staffing resources, nursing management and infection preventionists can use these results to help ensure that operational mechanisms, staff training, and adherence monitoring efforts effectively address the areas most associated with COVID-19 IPC noncompliance. [Journal of Gerontological Nursing, 49(2), 36-42.].

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19

Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2 decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.

Role of Nursing Home Quality on COVID-19 Cases and Deaths: Evidence from Florida Nursing Homes

The Coronavirus disease 2019 (COVID-19) disproportionately affects nursing home residents, resulting in an elevated risk for COVID-19 morbidity and mortality for this frail population. It is critical to understand whether nursing home quality is related to COVID-19 cases and deaths. Using publicly available data obtained from Centers for Medicare & Medicaid Services COVID-19 Nursing Home Dataset, Nursing Home Compare and Long-Term Care Focus, this study compares key nursing home characteristics, infection prevention and control deficiencies, and five-star ratings among Florida nursing homes with and without resident COVID-19 cases and deaths. The study further examines the association between facility and resident characteristics, quality indicators, and COVID-19 cases and deaths. Findings from our study indicate that through late October 2020, over 90% of Florida nursing homes have at least one resident case and 65% have at least one resident death. The likelihood of having COVID-19 cases is more related to ownership status, facility size and average occupancy rate, rather than quality indicators. Associations between infection prevention and control deficiencies, overall quality ratings, and presence of COVID-19 resident deaths varied across different phases of the pandemic (e.g., overall five-star rating was found related to the odds of having resident deaths after, but not during, the surging stage). Training, uptake, and adherence to infection control procedures are needed to better protect the vulnerable nursing home resident population.

Nursing Home Profit Margins and Citations for Infection Prevention and Control

OBJECTIVES

Recent rampant spread of COVID-19 cases in nursing homes has highlighted the concerns around nursing homes' ability to contain the spread of infections. The ability of nursing homes to invest in quality improvement initiatives may depend on resource availability. In this study, we sought to examine whether lower profit margins, as a proxy for lack of resources, are associated with persistent infection control citations.

DESIGN

We conducted a retrospective study.

SETTING AND PARTICIPANTS

Medicare-certified nursing homes in the US with financial and facility characteristics data (n = 12,194).

METHODS

We combined facility-level data on nursing home profit margins from Medicare Cost Reports with deficiency citation data from Nursing Home Compare (2017-2019) and facility characteristics data from LTCFocus.org. We descriptively analyzed infection control citations by profit margins quintiles. We used logistic regressions to examine the relationship between profit margin quintiles and citations for infection prevention and control, adjusting for facility and market characteristics.

RESULTS

About three-fourths of all facilities received deficiency citations for infection prevention and control during 1 or more years from 2017 to 2019 with about 10% of facilities cited in all 3 years. Facilities in the highest profit margin quintile had 7.6% of facilities with citations for infection prevention and control in each of the 3 years compared with 8.1%, 10.0%, 10.7%, and 13.7% for facilities in the fourth, third, second, and first quintiles of profit margins, respectively. Multivariable regressions showed that facilities with the lowest profit margins (first quintile) had 54.3% higher odds of being cited in at least 1 year and 87.6% higher odds of being cited in each of the 3 years compared with facilities with the highest profit margins (fifth quintile).

CONCLUSIONS AND IMPLICATIONS

Our findings indicate that nursing homes may need more resources to prevent citations for infection prevention and control.

Prevalence and persistency of deficiency citations in Florida assisted living facilities

BACKGROUND

Assisted living facilities (ALFs) are plagued with quality issues but there are limited studies on the quality of ALFs. In Florida, state surveyors conduct inspections of ALFs and cite and/or fine facilities that are in violation of regulations. Yet, we do not know the types of quality problems identified and the extent to which facilities repeat such problems. In this study, we begin to fill this gap in our understanding of ALFs quality by summarizing the deficiency citations in Florida ALFs.

METHODS

We obtained inspection citation data on 957 large ALFs (bed size ≥ 25) in Florida from 2012 to 2018. Citation data are summarized at the facility-year level and classified into different groups such as resident care, admissions, medication, staffing, and training. We examined the trends in citations over time and stratified citations by profit status, license type, and facility size. We also assessed repeat citations among the ALFs.

RESULTS

Of the 957 large ALFs operating in Florida, 87% of the facilities were cited one or more times from 2012 to 2018. In 2018, the most common citations were related to medications (26.2%), resident care (25.3%), training (25.3%), admissions (21.1%), and staffing (20.8%). For-profit facilities, facilities with beds over 100, and facilities with limited mental health license tended to be cited more often across most types of deficiencies. Repeat citations are common with over 40% of facilities cited in two or more years for resident care and medication from 2012 to 2018.

CONCLUSIONS

Our findings suggest that repeat citations are common and ALFs do not improve quality on a long-term basis after citations. If we want to improve ALFs quality, we may need to provide appropriate incentives and resources to ALFs along with stringent enforcement of regulations.

Association between nursing home staff turnover and infection control citations

OBJECTIVE

To describe the association between nursing home staff turnover and the presence and scope of infection control citations.

DATA SOURCES

Secondary data for all US nursing homes between March 31, 2017, through December 31, 2019 were obtained from Payroll-Based Journal (PBJ), Nursing Home Compare, and Long-Term Care: Facts on Care in the US (LTC Focus).

STUDY DESIGN

We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility's nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants.

DATA COLLECTION/EXTRACTION METHODS

We linked nursing homes standard inspection surveys to 650 million shifts from the PBJ data. We excluded any nursing home with incomplete or missing staffing data. Our final analytic sample included 12,550 nursing homes with 30,536 surveys.

PRINCIPAL FINDINGS

Staff turnover was associated with an increased likelihood of an infection control citation (average marginal effect [AME] = 0.12 percentage points [pp]; 95% confidence interval [CI]: 0.05, 0.18). LPN (AME = 0.06 pp; 95% CI: 0.01, 0.11) turnover was conditionally associated with an infection control citation. Conditional on having at least an isolated citation for infection control, staff turnover was positively associated with receiving a citation coded as a "pattern" (AME = 0.21 pp; 95% CI: 0.10, 0.32). Conditional of having at least a pattern citation, staff turnover was positively associated with receiving a widespread citation (AME = 0.21 pp; 95% CI: 0.10, 0.32).

CONCLUSIONS

Turnover was positively associated with the probability of an infection control citation. Staff turnover should be considered an important factor related to the spread of infections within nursing homes.

The relationship between quality and staffing in long-term care: A systematic review of the literature 2008-2020

BACKGROUND

Higher staffing levels in long-term care have been associated with better outcomes for residents in several landmark studies. However previous systematic reviews found mixed results, calling into question the effectiveness of higher levels of staff. With persistent concerns about quality, rising resident acuity, and a growing demographic of seniors requiring more services, understanding the relationship between quality and long-term care staffing is a growing concern.

OBJECTIVES

This review considered the following question: What is the influence of nursing and personal care staffing levels (registered nurse, licensed practical nurse, and nursing assistant) and / or skill mix on long-term care residents, measured by quality of care indicators?

DESIGN

Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guided the report of this systematic review.

DATA SOURCES

Published articles focused on quality and nursing and personal care staffing in long-term care in peer-reviewed databases (MEDLINE, CINAHL, and AGELINE) and several Cochrane databases to retrieve studies published between January 2008 and June 2020.

REVIEW METHODS

A systematic review was conducted. 11,096 studies were identified, of which 34 were included in this review. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to evaluate study quality and risk of bias, and five quality measures were selected for in-depth analyses: pressure ulcers, hospitalizations, physical restraints, deficiencies and catherization.

RESULTS

This review confirms previous review findings that evidence on the relationships between quality and long-term care staffing level and skill mix, remain mixed. Higher staffing levels and skill mix generally supported better rather than worse outcomes. Significant and consistent findings were more evident when staffing levels were further analyzed by indicator and staffing category. For example, registered nurses were consistently associated with significantly fewer pressure ulcers, hospitalizations, and urinary tract infections. Few studies examined the impact of total nursing and personal care hours compared to the impact of specific categories or classes of nursing staff on outcomes.

CONCLUSIONS

Evidence on the relationship between quality and long-term care staffing remains mixed, however some categories of nursing staff may be more effective at improving the quality of certain indicators. Study quality has improved minimally over the last decade. Although research continues to standardize units of measurement, and longitudinal and instrumental variable analyses are increasingly being used, very few studies controlled for endogeneity, conducted adequate risk-adjustment, and used resident-level data. Additional strides must still be made to improve the rigor of long-term care staffing research.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability

Objectives

To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States.

Design

Retrospective cohort study from November 27, 2017 to November 27, 2019.

Setting and Participants

In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies.

Methods

We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies.

Results

A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states’ NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times.

Conclusions and Implications

As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths

BACKGROUND

Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes.

METHODS

We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19.

RESULTS

The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership.

INTERPRETATION

For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

Exploring social-based discrimination among nursing home certified nursing assistants

Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social-based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social-based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social-based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower-class workers and subsequently improving resident care delivery.

Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial

Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.

Isolation Precautions Use for Multidrug-Resistant Organism Infection in Nursing Homes

OBJECTIVES

To examine factors associated with isolation precaution use in nursing home (NH) residents with multidrug-resistant organism (MDRO) infection.

DESIGN

Retrospective, cross-sectional analysis.

SETTING

Nursing homes with Centers for Medicare and Medicaid Services' certification from October 2010 to December 2013.

PARTICIPANTS

Elderly, long-stay NH residents with positive MDRO infection assessments.

MEASUREMENTS

Data were obtained from the Minimum Data Set (MDS) 3.0, Certification and Survey Provider Enhanced Reporting, and Area Health Resource File. Multivariable regression with facility fixed effects was conducted.

RESULTS

The sample included 191,816 assessments of residents with MDRO infection, of which isolation use was recorded in 12.8%. Of the NHs reporting MDRO infection in the past year, 31% used isolation at least once among residents with MDRO infection. Resident characteristics positively associated with isolation use included locomotion (23.6%, P < .001) and eating (17.9%, P < .001) support. Isolation use was 14.3% lower in those with MDRO history (P < .001). Residents in NHs that had received an infection control-related citation in the past year had a greater probability of isolation use (3.4%, P = .02); those in NHs that had received a quality-of-care citation had lower probability of isolation use (-3.3%, P = .03).

CONCLUSION

This is the first study to examine the new MDS 3.0 isolation and MDRO items. Isolation was infrequently used, and the proportion of isolated MDRO infections varied between facilities. Inspection citations were related to isolation use in the following year. Further research is needed to determine whether and when isolation should be used to best decrease risk of MDRO transmission and improve quality of care.

Infection Prevention and Control Programs in US Nursing Homes: Results of a National Survey

OBJECTIVES

The objectives of this study were to (1) obtain a national perspective of the current state of nursing home (NH) infection prevention and control (IPC) programs and (2) examine differences in IPC program characteristics for NHs that had and had not received an infection control deficiency citation.

DESIGN

A national cross-sectional survey of randomly sampled NHs was conducted and responses were linked with Certification and Survey Provider Enhanced Reporting (CASPER) and NH Compare data.

SETTING

Surveys were completed and returned by 990 NHs (response rate 39%) between December 2013 and December 2014.

PARTICIPANTS

The person in charge of the IPC program at each NH completed the survey.

MEASUREMENTS

The survey consisted of 34 items related to respondent demographics, IPC program staffing, stability of the workforce, resources and challenges, and resident care and employee processes. Facility characteristics and infection control deficiency citations were assessed using CASPER and NH Compare data.

RESULTS

Most respondents had at least 2 responsibilities in addition to those related to infection control (54%) and had no specific IPC training (61%). Although many practices and processes were consistent with infection prevention guidelines for NHs, there was wide variation in programs across the United States. Approximately 36% of responding facilities had received an infection control deficiency citation. NHs that received citations had infection control professionals with less experience (P = .01) and training (P = .02) and were less likely to provide financial resources for continuing education in infection control (P = .01).

CONCLUSION

The findings demonstrate that a lack of adequately trained infection prevention personnel is an important area for improvement. Furthermore, there is a need to identify specific evidence-based practices to reduce infection risk in NHs.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set

Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Assessing Nursing Care Needs of Children With Complex Medical Conditions: The Nursing-Kids Intensity of Care Survey (N-KICS)

Recent medical advances have resulted in increased survival of children with complex medical conditions (CMC), but there are no validated methods to measure their care needs.

OBJECTIVES/METHODS

To design and test the Nursing-Kids Intensity of Care Survey (N-KICS) tool and describe intensity of nursing care for children with CMC.

RESULTS

The psychometric evaluation confirmed an acceptable standard for reliability and validity and feasibility. Intensity scores were highest for nursing care related to infection control, medication administration, nutrition, diaper changes, hygiene, neurological and respiratory support, and standing program.

CONCLUSIONS

Development of a psychometrically sound measure of nursing intensity will help evaluate and plan nursing care for children with CMC.

Nurse workforce characteristics and infection risk in VA Community Living Centers: a longitudinal analysis

OBJECTIVE

To examine effects of workforce characteristics on resident infections in Veterans Affairs (VA) Community Living Centers (CLCs).

DATA SOURCES

A 6-year panel of monthly, unit-specific data included workforce characteristics (from the VA Decision Support System and Payroll data) and characteristics of residents and outcome measures (from the Minimum Data Set).

STUDY DESIGN

A resident infection composite was the dependent variable. Workforce characteristics of registered nurses (RN), licensed practical nurses (LPN), nurse aides (NA), and contract nurses included: staffing levels, skill mix, and tenure. Descriptive statistics and unit-level fixed effects regressions were conducted. Robustness checks varying workforce and outcome parameters were examined.

PRINCIPAL FINDINGS

Average nursing hours per resident day was 4.59 hours (SD=1.21). RN tenure averaged 4.7 years (SD=1.64) and 4.2 years for both LPN (SD=1.84) and NA (SD=1.72). In multivariate analyses RN and LPN tenure were associated with decreased infections by 3.8% (incident rate ratio [IRR]=0.962, P<0.01) and 2% (IRR=0.98, P<0.01) respectively. Robustness checks consistently found RN and LPN tenure to be associated with decreased infections.

CONCLUSIONS

Increasing RN and LPN tenure are likely to reduce CLC resident infections. Administrators and policymakers need to focus on recruiting and retaining a skilled nursing workforce.

State focus on health care-associated infection prevention in nursing homes

BACKGROUND

Despite increased focus on health care-associated infections (HAI), between 1.6 and 3.8 million HAI occur annually among the vulnerable population residing in US nursing homes (NH). This study characterized state department of health (DOH) activities and policies intended to improve quality and reduce HAI in NH.

METHODS

We created a 17-item standardized data collection tool informed by 20 state DOH Web sites, reviewed by experts in the field and piloted by 2 independent reviewers (Cohen's κ .45-.73). The tool and corresponding protocol were used to systematically evaluate state DOH Web sites and related links.

RESULTS

Three categories of data were abstracted: (1) consumer-directed information intended to increase accountability of and competition between NH, including mandatory HAI reporting and NH inspection reports; (2) surveyor training for federally-mandated NH inspections; and (3) guidance for NH providers to prevent HAI and monitor incidence. Only 5 states included HAI reporting in NH with differing HAI types and reporting requirements.

CONCLUSION

State DOH information and activities focused on NH quality and reducing HAI were inconsistent. Systematically characterizing state DOH efforts to reduce HAI in NH is important to interpret the effects of these activities.

Hand Hygiene Practices Reported by Nurse Aides in Nursing Homes

Information from nurse aides describing their opinions of hand hygiene practices in nursing homes including perceived barriers to hand hygiene is presented. The information comes from a questionnaire developed for this investigation, with items addressing compliance, facility guidelines and protocols, training, hand washing facilities and materials, and hand washing barriers. Information from 4,211 nurse aides (response rate of 56%) working in a nationally representative sample of 767 nursing homes (participation rate = 51%) is used. We find that 57.4% of nurse aides comply with hand washing when caring for residents most of the time, while 21.7% always comply. With facilities, 43.3% sometimes check that hand washing is performed. In summary, self-reported compliance was poor, and facilities and materials were often lacking. These findings are useful in identifying issues and interventions, including the need for further initiatives to address hand hygiene practices.

Hand hygiene deficiency citations in nursing homes

Hand hygiene (HH) is recognized as an effective way to decrease transmission of infections. Little research has been conducted surrounding HH in nursing homes (NHs). In this research, deficiency citations representing potential problems with HH practices by staff as identified in the certification process conducted at almost all US NHs were examined. The aims of the study were to identify potential relationships between these deficiency citations and characteristics of the NH and characteristics of the NH environment. We used a panel of 148,900 observations with information primarily coming from the 2000 through 2009 Online Survey, Certification, And Reporting data (OSCAR). An average of 9% of all NHs per year received a deficiency citation for HH. In the multivariate analyses, for all three caregivers examined (i.e., nurse aides, Licensed Practical Nurses, and Registered Nurses) low staffing levels were associated with receiving a deficiency citation for HH. Two measures of poor quality (i.e., [1] Quality of care deficiency citations and [2] J, K, or L deficiency citations, that is deficiency citations with a high extent of harm and/or more residents affected) were also associated with receiving a deficiency citation for HH. Given the percentage of NHs receiving deficiency citations for potential problems with HH identified in this research, more attention should be placed on this issue.