A registered nurse for 22 years, Anne Courliss-Lane, RN, IPC, spent 10 years with a focus on allergy, asthma, and immunology then the next 9 years in internal medicine and triage. She became an infection preventionist in 2019, when she started in long-term care. She has always had an interest in infection control and has been very involved in the study of virology since the beginning of the COVID-19 pandemic.

Anne Courliss-Lane, RN, IPC

A long-term care resident touching hands through a glass window during COVID-19 lockdowns. 

With the winter months fast approaching, I am reminded of being a child and wanting to play in the snow. Before I could go outside, I had to put on all the necessary gear to protect myself. I donned snow pants first, ensuring the inner liner was perfectly tucked into my boots. I zipped up a large heavy jacket to my chin, put on my scarf and hat, and wore gloves under my coat sleeves. As a parent today, I find myself going through the same motions but also putting all that gear on a toddler who doesn’t understand why. I can’t have an educated conversation with them about protecting their skin from frostbite or their body from hypothermia. They wiggle around, sometimes cry, and have zero patience for what I am trying to do to protect them. Both scenarios parallel the long-term care (LTC) environment, with the use of personal protective equipment (PPE) and the isolation and quarantine of residents, many of whom have dementia.

The COVID-19 pandemic has amplified existing challenges faced by LTC facilities. Trying to implement infection control measures, both person-centered and broad-based, is influenced by many factors that have led to a continuous uphill battle. To understand the complexity of these challenges, we should recognize where LTC was prior to the beginning of the pandemic and how things have changed since.

LTC facilities were created to integrate home and community. They allow those who have unmet personal and health care needs to have a safe place to live and remain close to their family and friends. LTC often involves the most intimate aspects of a person’s life, such as meal preparation and assistance with eating, bathing, dressing, and toileting. According to LongTermCare.gov, a website managed by the US Department of Health & Human Services, individuals 65 years or older have an almost 70% chance of needing long-term care in their remaining years, with 20% of those individuals needing it for more than 5 years.

 Because of these close interactions, sometimes extending over a long period of time, strong connections form between staff and residents. This relationship was of utmost importance during the COVID-19 pandemic, especially when visitors were denied access to their loved ones. At many times, staff not only functioned as direct care workers but also as surrogate family members during a resident’s last days.

Before COVID-19, the majority of LTC staff had never dealt with a novel infectious disease outbreak. The 2009 H1N1 influenza pandemic primarily affected children and young adults, and by August 10, 2010, the World Health Organization declared an end to the pandemic.

 Prior to COVID-19, antiviral chemoprophylaxis, adaptable vaccines, and quick implementation of infection control measures such as isolation and PPE use effectively halted outbreaks. The 2009 H1N1 was the last time N95 masks were needed in most nursing homes. When the SARS-CoV-2 virus entered our country in 2020, the entire nursing home industry was jolted into the unknown. It could either adapt and overcome or succumb.

Staff in LTC facilities faced many unique and difficult challenges during the COVID-19 pandemic. Infection preventionists were tasked with balancing strict infection control guidelines with the hardship those measures imposed on residents and staff. Because of the multitude of regulatory changes over the past 32 months, pandemic fatigue relating to PPE use, testing, and isolation has led to high levels of staff turnover and notable decline in residents’ overall health. According to one investigation,

 during the first year of the pandemic, nursing homes with active COVID-19 cases experienced significant increases in weight loss and depressive symptoms among residents. Even facilities that did not have known COVID-19 cases experienced adverse changes in some health and quality of life measures. (See Table.

Many LTC staff felt they were struggling with and left searching for ethical guidance when enforcing specific infection control measures, notably isolation and quarantine of the residents and repeated nasal swabs for testing. Not only was it physically exhausting to don a respirator, gown, goggles, and gloves every time they needed to go into a resident’s room, but it was mentally taxing to see residents confined to their rooms for an indefinite amount of time. Although we know that isolation and quarantine are effective infection control measures, enforcing them effectively in a population where an average 70% of residents have dementia

 was extremely challenging. These residents did not have the cognitive ability to understand why they could not come out of their rooms, and it was very difficult to keep them in there, especially those who had a need to wander. They also did not understand why staff kept trying to put a swab up their nose and would frequently turn their head away or physically refuse the testing.

What do you do when a wandering resident, who attained a positive result for COVID-19, continuously leaves their room, wiping their nose on their hand and using the handrails in the hallway? How do you handle a resident with COVID-19 who is asymptomatic, cannot understand they have a contagious illness, and asks staff every 5 minutes why they can’t leave their room, becoming emotionally distressed? How do you care for a resident with

COVID-19 who has frequent falls, but because of a safety risk, you cannot shut the door and may not have time to put on the required PPE to get into the room quick enough? How do you group residents or create an isolation unit when the physical layout of your facility doesn’t allow for it, and you don’t have the staff support you need? These are the tough questions an infection preventionist must answer on a daily basis in a nursing home. Sometimes there are no good answers, and you must do the best you can with what you have.

This is a defining moment for LTC facilities as the effects of the pandemic reach an inflection point. The COVID-19 virus will continue to be a defining part of nursing home culture, and infection preventionists remain front and center, charged with making person-centered decisions that also support the safety of the broader community. There are many barriers when it comes to implementing infection control measures, and staff will continue to need support and training for managing these unique situations.

2009 H1N1 pandemic (H1N1pdm09 virus). Centers for Disease Control and Prevention. June 11, 2019. Accessed October 26, 2022. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html

Barnett ML, Waken RJ, Zheng J, et al. Changes in health and quality of life in US skilled nursing facilities by COVID-19 exposure status in 2020. 

. 2022;328(10):941-950. doi:10.1001/jama.2022.15071

How much care will you need? ACL administration for community living. Accessed November 1, 2022. https://acl.gov/ltc/basic-needs/how-much-care-will-you-need

Articles

Integrating home and community, long-term care facilities are supposed to be a haven for patients and their families. But during the COVID-19 pandemic, keeping the patients and the staff safe was a constant battle. An infection preventionist who lived through it discusses the challenges at her facility.

LTC Facilities Face Unique Infection Control Issues During COVID-19 Pandemic 

Happy times at a nursing home (Adobe Stock) 

Back in the spring of 2019, when I first started as an infection preventionist (IP), I was amazed at how lovely working in a nursing home was. Coming from a busy internal medicine practice, this was just the change I was looking for. The facility was decorated for Easter, and numerous residents, family, and staff were sitting in a common area painting Easter eggs. One resident was playing the piano while others sang. This truly was a home. Working as an IP was busy, but seeing the smiles and laughter of the residents made it worth it.

Fast forward to a year later, spring of 2020. When COVID-19 arrived, many things changed within the facility, all related to infection control. As IPs, we were used to quietly working in the background, but now, we were front and center. The regulatory agencies started sending out epidemic orders containing mandatory changes to things such as personal protective equipment (PPE), testing, and vaccine mandates. We were responsible for instituting those changes, many of which nursing home workers never had had to endure before. Employees from all departments were now required to wear source control and be routinely swabbed for COVID-19. Those 2 things alone were enough to start driving some people away from the industry. Wearing an N95, the same N95, for 8-12 hours a day was unprecedented. The guidance for testing specified exactly how many days you had to have in between the screening testing and thus required staff to drive over on a day off to meet the requirements. In our rural community, this meant some staff driving over an hour 1 way to get here. Consequently, staff would correlate these rules and regulations to the IP or administration which would lead to feelings of animosity and frustration.

Compiled with the PPE and testing requirements was the constant stress and anxiety about bringing COVID-19 into the building and possibly giving it to a resident. There was a stigma associated with testing positive now and a strong feeling of guilt and worry as residents were subjected to COVID-19 testing and isolation day after day. There were no more parties, no more singing, and the smiles were covered by masks. As time went on, the regulations on nursing homes became even more demanding; all the while life out in the community was also changing. Many businesses were hurting for staff and offering wages and bonuses most nursing homes couldn’t compete with. Innumerable “help wanted” signs evidenced the general and severe lack of employees in the local economy. PPE fatigue and caregiver burnout were happening at an unparalleled rate, and many health care workers and residents had an overwhelming desire for some sense of normalcy. Staff voiced that they loved caring for their residents but just couldn’t do it anymore.

As an IP, I could relate to all the same things. We were functioning in a constant state of anxiety. Never knowing if a resident sneezed because of allergies or the onset of COVID-19. Most IPs were on call 24/7 now going on 2 and half years, working weekends, holidays, and all hours of the night trying to prevent an outbreak from happening and yet keeping up with all the other non-COVID-19 duties. Health care-associated infections (HAIs) were still happening, the water management program still needed to go on, and employee education never ends. The workload doubled or even tripled when adding in all the mandatory reporting. We were also being held accountable for the actions of visitors entering the facility, some who were confrontational, because as the rest of the world was seemingly moving on, nursing homes were still subject to strict infection control mandates. As misinformation spread, and the war on COVID-19 was now part of the political theatre, the staff had to deal with aggressive and abusive visitors who would refuse to follow our infection control protocols.

Nursing homes have struggled with staffing historically, but the pandemic exacerbated this issue exponentially. For us, it was a gradual decline. We are now staffed about 50% of what we were when the pandemic began. We are also running a census of 50% to parallel that, not for lack of patients on our waiting list, but to ensure we can safely take care of those we have. It has impacted all departments from support staff, to direct care staff, leadership, and administration. After all, we are all human—no matter our job title. We have had to hold an elder’s hand during their last moments because their families were not allowed to come in. We have had to try to keep residents with Alzheimers and dementia isolated to their rooms when they don’t have the cognitive ability to understand why. Many times residents were put into isolation because a staff member tested positive, and the resident, or their family, decided they didn’t want the vaccine or another booster shot. Facility employees continue to test positive, 1 here, 1 there. The regulations state that any resident who is not up-to date with their COVID-19 vaccines should be placed in their room, in quarantine, for at least 7 up to 10 days (it used to be 14), when just 1 staff member tests positive, even if that staff member had no contact with the resident. To put it in perspective, we have not gone 1 month without a positive staff case in over a year.

There is no magical answer to the staffing shortage. I applaud those who have stuck it out, side by side with their colleagues in the trenches. Every nursing home struggles in different areas, but some things can help with staff morale and longevity of employment. We all must work as a team. IPs must feel supported by their administration and the workload shared. It is too much for 1 person to bear alone. All leadership must be visible and accessible.

As an IP, I do rounds every morning, making a point to talk to floor staff, not only to check on the status of residents, but to check on the status of the floor staff themselves. Is there anything I can do to make their day a little easier? While pizza parties are nice, our staff need to truly feel appreciated, and we must continue to invest in their emotional well-being. Our facility hired a success coach to help any employee who may be struggling emotionally, physically, or financially and connects them to resources in the community. Our leadership team members donate a certain dollar amount out of each paycheck to put into an employee assistance program. These funds assist staff with satisfying basic unmet needs such as filling gas tanks, buying groceries, paying for daycare. We also make paid time off donations if someone is adversely affected with time off, especially related to COVID-19. While these things may help retain currently employed staff, it does not propose a solution to bringing in new ones. The staffing 

 from Centers for Medicare & Medicaid Services is another hurdle we will now have to overcome.

We are in a completely different place than we were in 2020. It is time to shift our focus and find our way back to being nursing homes. Somewhere we lost the home part. We have vaccines, therapeutics, prophylactic medications, non-pharmacologic interventions such as mask wearing, and so much more knowledge The outward façade of nursing homes needs to change. Once we are seen as a home again and not an institution, when the singing and dancing return inside these walls, maybe then will we also see a return of caregivers who want to work here again. For me, it’s about the honor and joy of caring for those who once cared for us.

Long-term care facilities were once normally happier places, but COVID-19 changed the individuals working and living there. PPEs, testing, overwork, underpayment, and too many isolations have chased health care workers away and forced the facilities' population to plummet. Can anything be done? 

Anne Courliss-Lane, RN, IPC

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