Governance of Assisted Living in Long-Term Care: A Systematic Literature Review

Assisted living (AL) is an emerging model of care in countries where long-term care needs are escalating, with emphasis given to promoting independence and autonomy among the residents to achieve active and healthy ageing. Unlike established nursing homes, the governance of AL is nebulous due to its novelty and diverse nature of operations in many jurisdictions. A comprehensive understanding of how AL is governed globally is important to inform regulatory policies as the adoption of AL increases. A systematic literature review was undertaken to understand the different levels of regulations that need to be instituted to govern AL effectively. A total of 65 studies, conducted between 1990 to 2020, identified from three major databases (PubMed, Medline, and Scopus), were included. Using a thematic synthesis analytical approach, we identified macro-level regulations (operational authorisation, care quality assessment and infrastructural requirements), meso-level regulations (operational management, staff management and distribution, service provision and care monitoring, and crisis management), and micro-level regulations (clear criteria for resident admission and staff hiring) that are important in the governance of AL. Large-scale adoption of AL without compromising the quality, equity and affordability would require clear provisions of micro-, meso- and macro-level regulations.

Shared Homes as an Alternative to Nursing Home Care: Impact of VA's Medical Foster Home Program on Hospitalization

PURPOSE OF THE STUDY

This study compares hospitalization rates for common conditions in the Veteran Affairs (VA) Medical Foster Home (MFH) program to VA nursing homes, known as Community Living Centers (CLCs).

DESIGN AND METHODS

We used a nested, matched, case control design. We examined 817 MFH residents and matched each to 3 CLC residents selected from a pool of 325,031. CLC and MFH cases were matched on (a) baseline time period, (b) follow-up time period, (c) age, (d) gender, (e) race, (f) risk of mortality calculated from comorbidities, and (g) history of hospitalization for the selected condition during the baseline period. Odds ratio (OR) and related confidence interval (CI) were calculated to contrast MFH cases and matched CLC controls.

RESULTS

Compared with matched CLC cases, MFH residents were less likely to be hospitalized for adverse care events, (OR = 0.13, 95% CI = 0.03-0.53), anxiety disorders (OR = 0.52, 95% CI = 0.33-0.80), mood disorders (OR = 0.57, 95% CI = 0.42-0.79), skin infections (OR = 0.22, 95% CI = 0.10-0.51), pressure ulcers (OR = 0.22, 95% CI = 0.09-0.50) and bacterial infections other than tuberculosis or septicemia (OR = 0.54, 95% CI = 0.31-0.92). MFH cases and matched CLC controls did not differ in rates of urinary tract infections, pneumonia, septicemia, suicide/self-injury, falls, other injury besides falls, history of injury, delirium/dementia/cognitive impairments, or adverse drug events. Hospitalization rates were not higher for any conditions studied in the MFH cohort compared with the CLC cohort.

IMPLICATIONS

MFH participants had the same or lower rates of hospitalizations for conditions examined compared with CLC controls suggesting that noninstitutional care by a nonfamilial caregiver does not increase hospitalization rates for common medical conditions.

Hepatitis B outbreak associated with a home health care agency serving multiple assisted living facilities in Texas, 2008-2010

We investigated a multifacility outbreak of acute hepatitis B virus infection involving 21 residents across 10 assisted living facilities in Texas during the period January 2008 through July 2010. Epidemiologic and laboratory data suggested that these infections belonged to a single outbreak. The only common exposure was receipt of assisted monitoring of blood glucose from the same home health care agency. Improved infection control oversight and training of assisted living facility and home health care agency personnel providing assisted monitoring of blood glucose is needed.

Infection prevention and control standards in assisted living facilities: are residents' needs being met?

BACKGROUND

Assisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities.

OBJECTIVES

Describe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training.

METHODS

We abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities.

RESULTS

Of the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating.

CONCLUSIONS

There is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.

Point-of-care tests for infection control: should rapid testing be in the laboratory or at the front line?

BACKGROUND

A point-of-care test (POCT) offers a rapid result to manage a patient immediately. The presumed simplicity of such tests belies observed variation between personnel in performing and interpreting results when not appropriately trained. The number of point-of-care devices being developed for the diagnosis of infectious diseases is increasing; by understanding the limitations associated with their use, such tests for infection control purposes may be possible.

AIM

To review the expanding repertoire of POCTs for the diagnosis of infectious diseases and to assess their utility as tools to aid in the reduction of hospital-acquired infection and outbreak management.

METHODS

A systematic review using PubMed and Scopus of published literature on the subject of POCTs for the diagnosis of infectious diseases.

FINDINGS

Although the number of publications describing POCTs is increasing, there remains a paucity of literature describing their use in a clinical setting. Of the literature reviewed, POCTs for the diagnosis of respiratory syncytial virus and norovirus have the greatest utility in an infection control setting, although the data suggest that sensitivity and training issues might be a problem. The future generation of POCT devices is likely to be molecular-based, improving sensitivity but at a significant cost to the user.

CONCLUSIONS

POCTs have a role in infection control but currently the lack of good, consistent clinical data surrounding their use outside of the laboratory is a limiting factor in their implementation.

Acute hepatitis B outbreaks in 2 skilled nursing facilities and possible sources of transmission: North Carolina, 2009-2010

OBJECTIVE

Acute hepatitis B virus (HBV) infections have been reported in long-term care facilities (LTCFs), primarily associated with infection control breaks during assisted blood glucose monitoring. We investigated HBV outbreaks that occurred in separate skilled nursing facilities (SNFs) to determine factors associated with transmission.

DESIGN

Outbreak investigation with case-control studies.

SETTING

Two SNFs (facilities A and B) in Durham, North Carolina, during 2009-2010.

PATIENTS

Residents with acute HBV infection and controls randomly selected from HBV-susceptible residents during the outbreak period.

METHODS

After initial cases were identified, screening was offered to all residents, with repeat testing 3 months later for HBV-susceptible residents. Molecular testing was performed to assess viral relatedness. Infection control practices were observed. Case-control studies were conducted to evaluate associations between exposures and acute HBV infection in each facility.

RESULTS

Six acute HBV cases were identified in each SNF. Viral phylogenetic analysis revealed a high degree of HBV relatedness within, but not between, facilities. No evaluated exposures were significantly associated with acute HBV infection in facility A; those associated with infection in facility B (all odds ratios >20) included injections, hospital or emergency room visits, and daily blood glucose monitoring. Observations revealed absence of trained infection control staff at facility A and suboptimal hand hygiene practices during blood glucose monitoring and insulin injections at facility B.

CONCLUSIONS

These outbreaks underscore the vulnerability of LTCF residents to acute HBV infection, the importance of surveillance and prompt investigation of incident cases, and the need for improved infection control education to prevent transmission.

Performance of a new meter designed for assisted monitoring of blood glucose and point-of-care testing

BACKGROUND

Blood glucose (BG) meters used for assisted monitoring of blood glucose (AMBG) require different attributes compared with meters designed for home use. These include safety considerations (i.e., minimized risk of blood-borne pathogen transmission), capability for testing multiple blood sample types, and enhanced performance specifications. The OneTouch® Verio™Pro+ BG meter is designed to incorporate all of these attributes.

METHODS

Meter accuracy was assessed in clinical studies with arterial, venous, and capillary blood samples with a hematocrit range of 22.9-59.8%. The effect of interferents, including anticoagulants, on accuracy was evaluated. The meter disinfection protocol was validated, and instructions for use and user acceptance of the system were assessed.

RESULTS

A total of 97% (549/566) of BG measures from all blood sample types and 95.5% (191/200) of arterial blood samples were within ±12 mg/dl or 12.5% of reference measurements. The system was unaffected by 4 anticoagulants and 57 of 59 endogenous and exogenous compounds; it was affected by 2 compounds: pralidoxime iodide and xylose. Bleach wipes were sufficient to disinfect the meter. Users felt that the meter's quality control (QC) prompts would help them to comply with regulatory requirements.

CONCLUSION

The meter provided accurate measurements of different blood samples over a wide hematocrit range and was not affected by 57 physiologic and therapeutic compounds. The QC prompts and specific infection-mitigating design further aid to make this meter system practical for AMBG in care facilities.

Outbreak of hepatitis B virus infections associated with assisted monitoring of blood glucose in an assisted living facility-Virginia, 2010

Introduction

In January 2010, the Virginia Department of Health received reports of 2 hepatitis B virus (HBV) infections (1 acute, 1 chronic) among residents of a single assisted living facility (ALF). Both infected residents had diabetes and received assisted monitoring of blood glucose (AMBG) at the facility. An investigation was initiated in response.

Objective

To determine the extent and mechanism of HBV transmission among ALF residents.

Design

Retrospective cohort study.

Setting

An ALF that primarily housed residents with neuropsychiatric disorders in 2 adjacent buildings in Virginia.

Participants

Residents of the facility as of March 2010.

Measurements

HBV serologic testing, relevant medical history, and HBV genome sequences. Risk ratios (RR) and 95% confidence intervals (CIs) were used to identify risk factors for HBV infection.

Results

HBV serologic status was determined for 126 (91%) of 139 residents. Among 88 susceptible residents, 14 became acutely infected (attack rate, 16%), and 74 remained uninfected. Acute HBV infection developed among 12 (92%) of 13 residents who received AMBG, compared with 2 (3%) of 75 residents who did not (RR  = 35; 95% CI, 8.7, 137). Identified infection control breaches during AMBG included shared use of fingerstick devices for multiple residents. HBV genome sequencing demonstrated 2 building-specific phylogenetic infection clusters, each having 99.8–100% sequence identity.

Limitations

Transfer of residents out of the facility prior to our investigation might have contributed to an underestimate of cases. Resident interviews provided insufficient information to fully assess behavioral risk factors for HBV infection.

Conclusions

Failure to adhere to safe practices during AMBG resulted in a large HBV outbreak. Protection of a growing and vulnerable ALF population requires improved training of staff and routine facility licensing inspections that scrutinize infection control practices.

Transmission of hepatitis B virus associated with assisted monitoring of blood glucose at an assisted living facility in New York State

BACKGROUND

Hepatitis B virus (HBV) transmission has been reported after patient-to-patient blood exposure during assisted monitoring of blood glucose (AMBG). Three assisted-living facility (ALF) residents who underwent AMBG developed acute HBV infection (HBVI) within 10 days. We investigated HBV transmission and implemented preventive measures.

METHODS

A retrospective cohort study was conducted. Infection control practices were assessed. HBVI screening was conducted for all staff and epidemiologically linked residents. Viral DNA sequences were compared for a subset of isolates.

RESULTS

Lancing devices and glucometers were shared among residents without proper sanitization. Serologic testing of all 34 residents with diabetes and 12 epidemiologically linked residents present during the exposure period detected 6 residents with diabetes with current HBVI and 4 residents with diabetes and 1 epidemiologically linked resident with previous HBVI. A cohort study of 32 individuals with diabetes identified AMBG as a significant risk factor for HBVI (relative risk, 6.7; 95% confidence interval, 1.7-26.3). Viral DNA sequences for 5 AMBG-exposed residents' isolates were identical, suggesting a common source.

CONCLUSIONS

AMBG was significantly associated with HBVI in ALF residents with diabetes. Despite clear preventive recommendations, bloodborne pathogen transmission continues to occur in the setting of AMBG. Strengthening direct care provider, infection preventionist, and health department partnerships with ALFs is crucial to ensure safe AMBG practices and prevent HBV transmission.

Characteristics, services, and infection control practices of New York City assisted living facilities, 2010

OBJECTIVES

To describe New York City (NYC) assisted living facility (ALF) characteristics, services offered, and infection control practices and to identify infection control barriers and unmet needs.

DESIGN

Cross-sectional.

SETTING

ALFs licensed or applying to be licensed in NYC.

PARTICIPANTS

Seventy ALFs; 70 of 77 eligible facilities participated (91% participation rate).

MEASUREMENTS

Telephone interview questions assessed ALF characteristics, services offered, and infection control practices, including glucometry practices.

RESULTS

ALFs provided a broad range of services, such as vaccination (90%), assistance with taking medication (75%), bathing and showering (33%), and blood glucose monitoring (90%). Ninety percent of the facilities had nurses on site (directly employed or through a contract agency). Five facilities reported that residents sometimes shared glucometers, and one reported that fingerstick devices were sometimes shared. The majority of facilities wanted educational materials for staff (83%) and residents (77%) on topics including influenza, respiratory illness, norovirus, standard precautions, and general infection control. ALFs had a range of sick leave policies and infection control training requirements. Eighty-nine percent of the facilities reported having designated staff responsible for infection control, although 50% had nonclinical job titles.

CONCLUSION

NYC ALFs were varied in terms of nursing services offered, characteristics, and residents' needs; therefore, public health agencies may need to be flexible in their assistance. Public health agencies should consider strengthening relationships with ALFs to identify unmet needs and gaps in services.

"Never events": hepatitis B outbreaks and patient notifications resulting from unsafe practices during assisted monitoring of blood glucose, 2009-2010

INTRODUCTION

Despite sustained public health efforts to publicize the risk of hepatitis B virus (HBV) infection outbreaks during assisted monitoring of blood glucose (AMBG), outbreaks continue to occur. Here, we highlight several outbreaks and patient notifications due to AMBG, discuss prevention initiatives, and highlight gaps that remain.

METHODS

We reviewed available data and information from investigations of health care-associated HBV infection outbreaks and patient notification events associated with AMBG in the United States between 2009 and 2010.

RESULTS

Four HBV infection outbreaks were reported, all in assisted living facilities. Common infection control breaches included use of reusable finger stick devices, which are intended for personal use, on multiple persons; use of BG meters for more than one person without cleaning and disinfection between each use; and comingling of contaminated and clean equipment and supplies. Twenty-nine (88%) of the 33 residents who acquired acute HBV infection as part of these outbreaks received AMBG. Compared with those who did not, residents undergoing AMBG had significantly increased risk of acquiring acute HBV infection (relative risk: 27.7, 95% confidence interval: 10.3 to 74.4). During two patient notifications, approximately 320 persons were recommended to undergo bloodborne pathogen testing after being placed at risk for exposure to another person's blood when personal-use multilancet finger stick devices were selected for use on multiple persons.

CONCLUSIONS

Misperception on the risk for bloodborne pathogen transmission and confusion regarding selection and appropriate use of BG monitoring devices for AMBG remain a problem. In addition to public health outreach and infection control recommendations, clear labeling, packaging, instructions for device use, and appropriate device marketing will assist in infection prevention efforts.

Evaluation of hepatitis B vaccine immunogenicity among older adults during an outbreak response in assisted living facilities

BACKGROUND

During the past decade, in the United States, an increasing number of hepatitis B outbreaks have been reported in assisted living facilities (ALFs) as a result of breaches in infection control practices. We evaluated the seroprotection rates conferred by hepatitis B vaccine among older adults during a response to an outbreak that occurred in multiple ALFs and assessed the influence of demographic and clinical factors on vaccine response.

METHODS

Residents were screened for hepatitis B and C infection prior to vaccination and susceptible residents were vaccinated against hepatitis B with one dose of 20 μg Engerix-B™ (GSK) given at 0, 1, and 4 months. Blood samples were collected 80-90 days after the third vaccine dose to test for anti-HBs levels.

RESULTS

Of the 48 residents who had post-vaccination blood specimens collected after the third vaccine dose, 16 (33.3%) achieved anti-HBs concentration ≥10 mIU/mL. Age was a significant determinant of seroprotection with rates decreasing from 88% among persons aged ≤60 years to 12% among persons aged ≥90 years (p=0.001). Geometric mean concentrations were higher among non-diabetic than diabetic residents, however, the difference was not statistically significant (5.1 vs. 3.8 mIU/mL, p=0.7).

CONCLUSIONS

These findings highlight that hepatitis B vaccination is of limited effectiveness when administered to older adults. Improvements in infection control and vaccination at earlier ages might be necessary to prevent spread of infection in ALFs.

Five hepatitis B outbreaks in care homes in the UK associated with deficiencies in infection control practice in blood glucose monitoring

Healthcare-associated hepatitis B virus (HBV) outbreaks have been reported in the USA and from several countries in Europe. Patient-to-patient transmission of HBV in these settings has been linked to several different types of exposure but one of the most common exposures implicated is the use of ‘finger-stick’ lancet devices for blood glucose testing. This article is an account of the investigations into a series of HBV outbreaks linked to the use of lancing devices in community healthcare settings in the UK. Between February 2004 and December 2006, nine individuals with acute HBV infection were reported to five local units of the Health Protection Agency. Investigations identified a further 12 individuals with HBV infection in residents in these settings. The epidemiological and environmental evidence suggests that HBV transmission occurred mostly from a significant breakdown in infection control measures in blood glucose testing. The occurrence of these outbreaks has highlighted the confusion that exists and the need for clear recommendations regarding the use of such devices in the UK.

US outbreak investigations highlight the need for safe injection practices and basic infection control

Current understanding of viral hepatitis transmission in United States health care settings indicates progress over the past several decades with respect to the risks from transfusions or blood products. Likewise, risks to health care providers from sharps injuries and other blood and body fluid exposures have been reduced as a consequence of widespread hepatitis B vaccination and the adoption of safer work practices. Increasing recognition of outbreaks involving patient-to-patient spread of hepatitis B and hepatitis C virus infections, however, has uncovered a disturbing trend. This article highlights the importance of basic infection control and the need for increased awareness of safe injection practices.

Eliminating the blood: ongoing outbreaks of hepatitis B virus infection and the need for innovative glucose monitoring technologies

BACKGROUND

As part of routine diabetes care, capillary blood is typically sampled using a finger-stick device and then tested using a handheld blood glucose meter. In settings where multiple persons require assistance with blood glucose monitoring, opportunities for bloodborne pathogen transmission may exist.

METHODS

Reports of hepatitis B virus (HBV) infection outbreaks in the United States that have been attributed to blood glucose monitoring practices were reviewed and summarized.

RESULTS

Since 1990, state and local health departments investigated 18 HBV infection outbreaks, 15 (83%) in the past 10 years, that were associated with the improper use of blood glucose monitoring equipment. At least 147 persons acquired HBV infection during these outbreaks, 6 (4.1%) of whom died from complications of acute HBV infection. Outbreaks appear to have become more frequent in the past decade, primarily affecting long-term care residents with diabetes. Each outbreak was attributed to glucose monitoring practices that exposed HBV-susceptible persons to blood-contaminated equipment that was previously used on HBV-infected persons. The predominant unsafe practices were the use of spring-loaded finger-stick devices on multiple persons and the sharing of blood glucose testing meters without cleaning and disinfection between uses.

CONCLUSION

Hepatitis B virus infection outbreaks associated with blood glucose monitoring have occurred with increasing regularity in the Unites States and may represent a growing but under-recognized problem. Advances in technology, such as the development of blood glucose testing meters that can withstand frequent disinfection and noninvasive glucose monitoring methods, will likely prove useful in improving patient safety.