Hand hygiene deficiency citations in nursing homes

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.].

Visibility and Accessibility of Hand Hygiene Stations and Fatigue Among Nurses Working in Long-Term Care (LTC) During the COVID-19 Pandemic

OBJECTIVES

Evaluate the relationship between nurses' perception of the long-term care (LTC) environment, specifically having visible and accessible hand hygiene stations (HHS), and nurses' fatigue during the COVID-19 pandemic.

BACKGROUND

LTC nurses experience not only heavy workloads and fatigue but also a high risk of infection during the COVID-19 pandemic. Few studies have evaluated the relationship between safety measures such as having visible and accessible HHS and nurses' fatigue.

METHODS

The cross-sectional COVID-19 Impact on Nurses Study (COINS) was an online survey distributed to members of the American Association of Post-Acute Care Nursing through the REDCap survey platform, between June 1, 2020, and January 31, 2021. Logistic regression modeling was conducted to identify the relationship between nurses' perception of having visible and accessible HHS and fatigue among LTC nurses.

RESULTS

The majority of LTC nurse respondents (78.35%) reported having moderate to very severe fatigue. Nurses who reported not having enough visible and accessible HHS in their work environment have statistically significantly higher odds (odds ratio [OR] = 0.37, 95% confidence interval [CI] [0.20, 0.70], p = .002) of reporting experiencing moderate to very severe fatigue compared to nurses who perceived there was adequate HHS. The logistic regression is significant while controlling for sociodemographic differences, guilt for family and patients, support from work, and confidence in the future of LTC.

CONCLUSIONS

This study reveals the LTC environment that incorporates better considerations of more visible and accessible HHS might mitigate nurses' fatigue during the pandemic. A conceptual framework has been proposed for future studies.

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.

Students' observations of hand hygiene adherence in 20 nursing home wards, during the COVID-19 pandemic

BACKGROUND

Healthcare-associated infections are a major threat to patient safety, particularly vulnerable elderly living in nursing homes, who have an increased risk of infections and mortality. Although good hand hygiene is the most effective preventive measure against infections, few studies of hand hygiene adherence have been conducted in nursing homes. The aim of this study is to investigate hand hygiene adherence in nursing homes with students as observers using a validated observation tool. In addition, to examine when healthcare workers perform hand hygiene and when they do not.

METHODS

This observational study used the World Health Organization's observation tool for studying hand hygiene indication and adherence: "My five moments for hand hygiene." For 1 week each in February and March 2021, 105 first-year nursing students conducted 7316 hand hygiene observations at 20 nursing home wards in one large municipality in Norway.

RESULTS

The overall adherence rate found in this study was 58.3%. Hand hygiene adherence decreased from 65.8% in February to 51.4% in March. The adherence varied largely between the different wards, from 26.4 to 83.1%, and by occupation status, indications of hand hygiene, and use of gloves. Nursing students were found to have the greatest adherence, followed by nurses. The use of gloves reduced adherence. Healthcare workers to a larger degree conduct hand hygiene after contact with patients than before approaching them.

CONCLUSIONS

Hand hygiene adherence is too low to protect all residents against healthcare-associated infections, and the findings from this study indicate that there are many factors that influence hand hygiene adherence, eg., education, occupation status and glove use Increasing healthcare workers' knowledge and skills of hand hygiene is needed to reduce healthcare-associated infections and reminders of the importance of hand hygiene adherence must be an ongoing activity. Interventions to improve hand hygiene adherence in healthcare workers is needed to reduce infections and antibiotic use in nursing homes.

Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced survey program 2018 to 2019

BACKGROUND

The VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents.

PURPOSE

To describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services.

METHODS

Using CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis.

FINDINGS

We identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems.

DISCUSSION

Our analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.

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.

Students' observations of hand hygiene in nursing homes using the five moments of hand hygiene

AIMS AND OBJECTIVES

To use nursing students to observe hand hygiene adherence in nursing homes and to explore whether the students' reflections after observing hand hygiene practices gives them a deeper understanding of the subject matter.

BACKGROUND

Residents in nursing homes worldwide have low tolerance for healthcare-associated infections that require antibiotics, and hand hygiene is the single most effective action to reduce infections.

DESIGN

Observational study using (a) World Health Organization's (WHO) "Five moments for hand hygiene" validated tool to record indications and adherence and (b) an exploratory study of individual reflection notes from students conducted during and after observations.

METHODS

From February 12-15, 2018, 26 nursing students in their second semester of a 3-year bachelor programme participated as observers in five wards in four nursing homes in the Oslo metropolitan area. This study was performed according to the STROBE statement.

RESULTS

Hand hygiene was performed for 57.2% of the 2,393 indications observed and recorded. Adherence differed significantly by type of personnel and by location. Four thematic categories emerged from the reflection notes: (a) practical awareness and introspection; (b) visualisation and enhancement of understanding of practice learning; (c) incorrect hand hygiene practices; and (d) stimulation to increase essential knowledge.

CONCLUSION

Hand hygiene adherence was too low to prevent healthcare-associated infections and to reduce the use of antibiotics. The students' reflection notes indicated more "insight and understanding of the complexity of hand hygiene." We suggest using nursing students in clinical placement as a means of incorporating different interventions as part of their learning skills and become "living reminders" of the importance of hygiene and infection prevention.

RELEVANCE FOR CLINICAL PRACTICE

Improving the student's activity about hygiene and infection prevention in clinical placement may help to raise awareness by healthcare workers in nursing homes.

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.

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.