Infection preventionist staffing in nursing homes

Dementia, nurse staffing, and health outcomes in nursing homes

OBJECTIVE

To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.

DATA SOURCES AND STUDY SETTING

A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.

STUDY DESIGN

Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.

DATA COLLECTION/EXTRACTION METHODS

Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.

PRINCIPAL FINDINGS

We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.

CONCLUSIONS

These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Harnessing the power of infection prevention and public health data systems to support health care in Washington State during the COVID-19 pandemic

BACKGROUND

State health departments' (SHD) role in infection prevention and control (IPC) includes robust educational and consultative services for various health care settings. During the COVID-19 pandemic, Washington-SHD (W-SHD) IPC staff conducted remote and on-site Infection Control Assessment and Response (ICAR) consultations for long-term care (LTC) and non-LTC health care facilities.

METHODS

ICAR consultations were classified as "reactive" in response to a COVID-19 outbreak or "proactive" to help facilities improve IPC protocols. Facility addresses were geocoded to census tracks, classifying urban or rural areas. Facility types and characteristics were analyzed, assessing the impacts of repeat visits. All descriptive statistics, Pearson's χ2 tests, and odds ratios were calculated.

RESULTS

Between March 2020 and December 2022, W-SHD conducted 3,093 ICARs at 1,703 health care facilities in 94.9% (37/39) of Washington counties. Of the total visits, most were in LTC (90.5%) and 48.9% were reactive. Facilities with initial on-site ICARs had 1.5 times the odds of having a repeat visit than facilities with initial remote visit (95% CI: 1.21, 1.87).

DISCUSSION

Maintaining strong connections with health care facilities can help bolster infection prevention practices and minimize loss of information at the facility level.

CONCLUSIONS

Evidence-based findings on the sustainability of the W-SHD's ICAR services during the COVID-19 pandemic illustrated the value of public health IPC programs.

A severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nosocomial cluster with inter-facility spread: Lessons learned

BACKGROUND

Despite infection control guidance, sporadic nosocomial coronavirus disease 2019 (COVID-19) outbreaks occur. We describe a complex severe acute respiratory coronavirus virus 2 (SARS-CoV-2) cluster with interfacility spread during the SARS-CoV-2 δ (delta) pandemic surge in the Midwest.

SETTING

This study was conducted in (1) a hematology-oncology ward in a regional academic medical center and (2) a geographically distant acute rehabilitation hospital.

METHODS

We conducted contact tracing for each COVID-19 case to identify healthcare exposures within 14 days prior to diagnosis. Liberal testing was performed for asymptomatic carriage for patients and staff. Whole-genome sequencing was conducted for all available clinical isolates from patients and healthcare workers (HCWs) to identify transmission clusters.

RESULTS

In the immunosuppressed ward, 19 cases (4 patients, 15 HCWs) shared a genetically related SARS-CoV-2 isolate. Of these 4 patients, 3 died in the hospital or within 1 week of discharge. The suspected index case was a patient with new dyspnea, diagnosed during preprocedure screening. In the rehabilitation hospital, 20 cases (5 patients and 15 HCWs) positive for COVID-19, of whom 2 patients and 3 HCWs had an isolate genetically related to the above cluster. The suspected index case was a patient from the immune suppressed ward whose positive status was not detected at admission to the rehabilitation facility. Our response to this cluster included the following interventions in both settings: restricting visitors, restricting learners, restricting overflow admissions, enforcing strict compliance with escalated PPE, access to on-site free and frequent testing for staff, and testing all patients prior to hospital discharge and transfer to other facilities.

CONCLUSIONS

Stringent infection control measures can prevent nosocomial COVID-19 transmission in healthcare facilities with high-risk patients during pandemic surges. These interventions were successful in ending these outbreaks.

The association of nursing home infection preventionists' training and credentialing with resident COVID 19 deaths

BACKGROUND

Nursing home (NH) residents' vulnerability to COVID-19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID-19 deaths.

METHODS

This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID-19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility-level weekly deaths per 1000 residents as a function of facility characteristics, and county-level COVID-19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated.

RESULTS

Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID-19 death rates (-1.04 deaths per 1000 residents; 95% CI -1.90, -0.18), and NHs employing IPs who were LPNs with training had lower COVID-19 death rates (-1.09 deaths per 1000 residents; 95% CI -2.07, -0.11) in adjusted models.

CONCLUSIONS

NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted.

Long-Term Care and the COVID-19 Pandemic: Lessons Learned

US nursing homes and other long-term care (LTC) communities such as assisted living and adult day care services have been disproportionally affected by COVID-19. Nurses and health care workers provided care and services despite health concerns for themselves and family members. Nurses on the frontline were called to act with extraordinary tenacity, skill, flexibility, and creativity to prevent infection; prevent complications; and optimize function, health, and well-being. The purpose of this article is to provide an overview of the challenges posed by the COVID-19 pandemic and the strategies prioritized and implemented by nurse and interdisciplinary colleagues in LTC settings.

Remote Infection Control Assessments of U.S. Nursing Homes During the COVID-19 Pandemic, April to June 2020

Background

Nursing homes (NHs) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NHs were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff.

Objective

To assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps.

Design

We incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering 6 domains: visitor restrictions; health care personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility.

Setting and Participants

Health department–referred NHs that agreed to TeleICAR consultation.

Methods

We assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment.

Results

During April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NHs across 19 states. Overall, 524 (83%) had ≥1 implementation gap identified; the median number of gaps was 2 (interquartile range: 1-4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625; 68%) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620; 47%).

Conclusions and Implications

TeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NHs across the United States early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

Infection prevention and control in nursing homes during COVID-19: An environmental scan

To examine processes and programmatic elements of infection prevention and control (IPC) efforts and identify themes and promising approaches in nursing homes (NHs), an environmental scan was conducted. Data sources included a literature search, relevant listservs and websites, and expert consensus based on a virtual summit of leaders in IPC in long-term care settings. Three thematic areas emerged which have the potential to improve overall IPC practices in the long-term care setting: staffing and resource availability, training and knowledge of IPC practices, and organizational culture. If improved IPC practices and reduced cross-transmission of infections in NHs are to be sustained, both short-term and long-term changes in these areas are essential to fully engage staff, build trust, and enhance a 'just' organizational culture.

Infection preventionists' experiences during the first nine months of the COVID-19 pandemic: Findings from focus groups conducted with Association of Professionals in Infection Control & Epidemiology (APIC) members

INTRODUCTION

A novel human Coronavirus (SARS CoV-2) was identified in January, 2020 and developed into a pandemic by March, 2020. This rapid, enormous, and unanticipated event had major implications for healthcare. Infection preventionists (IP) have a critical role in worker and patient safety. IPs' lessons learned can guide future pandemic response.

METHODS

Seven focus groups were conducted with APIC members in September and October, 2020 via Zoom to elicit IPs' experiences during the COVID-19 pandemic. Sessions were recorded then transcribed verbatim. Major themes were identified through content analysis.

RESULTS

In total, 73 IPs participated (average of 10 IPs per focus group) and represented all geographical areas and work settings. Participating IPs described multiple challenges they have faced during the COVID-19 pandemic, including rapidly changing and conflicting guidance, a lack of infection prevention recommendations for nonacute care settings, insufficient personal protective equipment, healthcare personnel complacency with personal protective equipment and infection prevention protocols, and increases in healthcare associated infections and workload.

CONCLUSIONS

The identified gaps in pandemic response need to be addressed in order to minimize healthcare associated infections and occupational illness. In addition, the educational topics identified by the participating IPs should be developed into new educational programs and resources.

Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis

Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988-2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran's Q = 166,837.8, p < .001, I² = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.

Implementation of core elements of antibiotic stewardship in nursing homes-National Healthcare Safety Network, 2016-2018

OBJECTIVE

To assess the national uptake of the Centers for Disease Control and Prevention's (CDC) core elements of antibiotic stewardship in nursing homes from 2016 to 2018 and the effect of infection prevention and control (IPC) hours on the implementation of the core elements.

DESIGN

Retrospective, repeated cross-sectional analysis.

SETTING

US nursing homes.

METHODS

We used the National Healthcare Safety Network (NHSN) Long-Term Care Facility Component annual surveys from 2016 to 2018 to assess nursing home characteristics and percent implementation of the core elements. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all 7 core elements while controlling for confounding by facility characteristics.

RESULTS

We included 7,506 surveys from 2016 to 2018. In 2018, 71% of nursing homes reported implementation of all 7 core elements, a 28% increase from 2016. The greatest increases in implementation from 2016 to 2018 were in education (19%), reporting (18%), and drug expertise (15%). In 2018, 71% of nursing homes reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. Nursing homes that reported at least 20 hours of IPC activity per week were 14% (95% confidence interval, 7%-20%) more likely to implement all 7 core elements when controlling for facility ownership and affiliation.

CONCLUSIONS

Nursing homes reported substantial progress in antibiotic stewardship implementation from 2016 to 2018. Improvements in access to drug expertise, education, and reporting antibiotic use may reflect increased stewardship awareness and resource use among nursing home providers under new regulatory requirements. Nursing home stewardship programs may benefit from increased IPC staff hours.

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.

The Winter Respiratory Viral Season During the COVID-19 Pandemic

The winter respiratory virus season always poses challenges for long-term care settings; this winter, severe acute respiratory syndrome coronavirus 2 will compound the usual viral infection challenges. This special article discusses unique considerations that Coronavirus Disease 2019 (COVID-19) brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. Specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. Policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a COVID-19 vaccine when it becomes available. Research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. If there is a positive side to this year's winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection.