SHARON WARD-FORE, MS, MT(ASCP), CIC, FAPIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

By Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC

Cleaning and disinfection are critical and will always be an essential focus as health care professionals work to mitigate the spread of health care–acquired infections (HAIs). Yet, as new advances in disinfectants and disinfection technology continue to emerge, an overlooked issue continues to intensify and must be addressed.

Surface material and product damage caused by surface disinfection incompatibility impedes effective cleaning and disinfection, costs health care facilities millions of dollars annually, and creates dangerous safety issues for patients and health care personnel. There are many different materials and textiles within a health care facility, and they cannot all be cleaned and disinfected the same way. When they are, damage occurs. First, at a microscopic level, and then it continues until the damage is clearly visible.

It is impossible to deal with a microbial issue at a macro level. We all know microbes can’t be seen. Visual inspections following disinfection do not provide information about what remains on and in surfaces at a microbial level. Surface damage caused by incompatible disinfection methods—cracks, fissures, and pits—provides microscopic reservoirs for microbial attachments, colonization, and biofilm formation. This provides pathogens a potential safe harbor away from the biocides used to disinfect the surfaces, placing patients and health care personnel at risk for contracting infections.

Many factors influence microbial attachment. It is critical to have a basic understanding of what can remain on surfaces after cleaning and disinfection. Well-documented research provides insight into the role surfaces play in acquiring and transmitting microbes that cause deadly infections. In a February 2021 

, Zheng et al describe in detail how microbes attach to surfaces.

Surface damage can support microbial attachment, colonization, and ultimately, biofilm formation. Biofilm is a complex matrix of extracellular polymeric substances that protect against environmental adversities. Once biofilm is formed, killing the bacteria or removing the biofilm that protects them is extremely difficult, as is disinfecting damaged surfaces where microbial reservoirs have been created. The selection of surfaces that are compatible with disinfectants used in the health care setting is critical during the design of products or the built environment.

A Case Study on Surface Disinfection Incompatibility

Because of the complexity of this problem, many facilities pay high costs for repair, replacement, and ongoing maintenance for medical equipment. In many cases, the cause of the problem is overlooked. In a jointly released case study,

 the Healthcare Surfaces Institute (HSI) and the Association of Healthcare Value Analysis Professionals conducted a deep-dive analysis to understand the root cause of damage to a medical device.

A large midwestern hospital, with approximately 700 licensed beds and over 1.2 million patient encounters yearly, purchased several hundred state-of-the-art, noninvasive optical sensor medical device monitoring systems. There was visible damage to the monitoring systems within 2 years because of chemical exposure during the disinfection process. Such damage is susceptible to unreachable microbial reservoirs that inhibit disinfection, creating severe liability and costs for the hospital and manufacturer.

The Challenges and Gaps That Were Identified

The medical device company identified a lack of understanding and discussion about infection prevention products and guidelines used within the hospital. Although the medical device company met with many key decision makers, there was no central point of contact for them to work through, resulting in a breakdown of communication and the lack of involvement of critical experts during the evaluation process. Also, health care experts were excluded from initial meetings before the damage occurred; had they been consulted, it is possible some issues could have been avoided.

The case study also provided a clear example of the lack of guidelines and testing requirements for surface materials and products. When the medical device company applied for US Food and Drug Administration (FDA) 510(k) clearance, which is a process that evaluates a device’s safety against comparable legally marketed devices, they had testing done for surface disinfection and compatibility. The company was left to determine which cleaning agents to recommend for testing. Only 1 disinfectant was tested. The case study found that the hospital’s infection prevention and control guidelines did not support the use of the only disinfection method prescribed by the medical device manufacturer. The hospital was left to find an alternative for disinfection after purchasing the devices.

The fact that there are no guidelines or minimum testing requirements to validate surface disinfection compatibility is a problem. Minimum testing should require all categories of US Environmental Protection Agency (EPA)-registered hospital-grade disinfectants. There are hundreds of proprietary disinfectant products on the market in addition to no-touch technologies, and it would be cost prohibitive to test all disinfectants. However, by testing the categories of disinfectants, foundational information can be gained. Going beyond the minimum testing and working with the disinfectant companies from which hospitals purchase products will be essential.

Also discovered during this investigation were conflicting instructions for use (IFU) and care and maintenance manuals. The IFU provided information for the possible use of 2 other disinfectants. However, in small print was a warning against the use of the alternative disinfectant selected by the hospital, as there was concern that it may cause corrosion. Unfortunately, the small print was not noticed until the damage had occurred.

It was also determined that not all health care personnel were trained for cleaning and disinfection, such as their nursing staff disinfecting part of the device during patient care. They did not have access to the information they needed and were not offered the basic training.

Materials were not tested or evaluated for cleanability during the surface material selection process and before product development. It is currently not common for raw material manufacturers to test their materials for surface disinfection compatibility before selling them to manufacturers, which is missing a vital step. Product designers must have this information to support that the product’s design can be cleaned and disinfected without damage.

It was noted that medical suppliers benefit from having coordinated access to clinical staff for feedback on successes and potential device improvements. It is important to include critical information about the cleaning and disinfecting agents and processes used within the hospital. The information gained will support the manufacturer as they identify disinfectants for testing.

Before purchasing the monitoring device, the hospital’s evaluation and selection process would have benefited from active participation from a diverse group of health care professionals responsible for infection prevention, including environmental service, infection prevention, biomedical, nursing, and clinical professionals. All these professionals evaluate products differently, and the combined knowledge and discussion provides valuable insight into potential challenges and successes.

In the past 6 months, several medical device manufacturers faced FDA recalls for surface disinfectant incompatibility issues that caused risk to patients. Each of the recalls resulted in a requirement to do additional testing for surface disinfection compatibility and the rewriting of IFUs. Recalls are costly and could be avoided if guidelines and minimum testing recommendations were identified and followed.

Infection preventionists can help drive more awareness about surface disinfection compatibility. We can start with collaboration with health care personnel, biomed, raw material suppliers, device manufacturers and designers, and disinfectant manufacturers. We can bring together all the different groups working on surfaces to help health care facilities understand the importance of surface disinfection compatibility, surface disinfectant testing, IFUs, and how they are all tied together. We must work together to achieve the following:

Develop a minimum standard for surface disinfectant compatibility that tests categories of disinfectants instead of proprietary products.

 If categories of disinfectant chemistries are tested rather than specific brand names, this helps simplify and clarify IFUs. This allows health care facilities to determine whether the products they already use are compatible with their equipment and medical devices. HSI has developed minimum testing standards, using 7 categories of EPA-registered, hospital-grade disinfectants. By bringing this issue to the forefront and addressing the issue at a microbial level, we will begin to see sustainable solutions to mitigate the spread of HAIs.

Designate a single point of contact within a health care organization to facilitate collaboration between manufacturers and health care professionals and to communicate important matters to all parties.

 Health care facilities and systems have equipment and medical devices that are damaged or placed out of service for reasons not always known to staff. Having 1 “point person” to report equipment and device issues to, such as damage from cleaning products, would be invaluable.

Establish a greater understanding of real-life challenges health care professionals face when working to mitigate the spread of infections within the health care setting. 

Medical device designers and manufacturers and disinfectant manufacturers do their best to create products that help keep patients and staff safe. However, sometimes there is a disconnect between the users and the vision research and development had in mind. A product with multiple nooks and crannies—although helpful in the design and build of a device—can pose a nightmare for cleaning and disinfection.

­­­­Build awareness around the selection of surface materials during the design phase by medical device manufacturers based on surface disinfection compatibility.

 Raw materials must meet minimum standard requirements. The number of different types of medical devices and equipment is overwhelming. When you consider all the possible surface material components, such as plastics, metals, and coatings, it’s not hard to see how easily surface disinfection incompatibility can happen.

Create guidelines for product reviews before purchase, as well as checklists for health care selection teams within the health care setting that provide essential information for product value analysis professionals.

 Infection preventionists already have guidelines or checklists to help evaluate disinfectants. They also need tools for assessing surface disinfection compatibility to determine whether a surface material or product can be safely cleaned and disinfected without causing damage that can harbor and transmit dangerous pathogens.

Medical device suppliers should provide maintenance training, including a review of cleaning and disinfection for all users of their equipment or devices.

The lack of attention paid to surface disinfection compatibility with patient care equipment and devices results in damage, failure, and recalls of expensive—and sometimes critical—patient care equipment. Addressing the issue of surface disinfection compatibility can help prevent these financial losses. However, understanding how critical the issue of surface disinfection compatibility is to protect patients and keep health care personnel safe when handling patient care equipment and devices is more important. Infection preventionists can help drive the change needed to address surface disinfection compatibility in health care.

Zheng S, Bawazir M, Dhall A, et al. Implication of surface properties, bacterial motility, and hydrodynamic conditions on bacterial surface sensing and their initial adhesion. 

. 2021;9:643722. doi:10.3389/fbioe.2021.643722

Surface disinfection incompatibility with medical devices creates potential patient risks. Healthcare Surfaces Institute. September 2021. Accessed March 11, 2022. https://www.healthcaresurfacesinstitute.org/case-studies/surface-disinfection-incompatibility-with-medical-devices-creates-potential-patient-risks/

Articles

The surface material and product damage caused by new advances in disinfection technology must be addressed for patient safety.

Surface Disinfection Incompatibility Does Not Support Effective Cleaning and Disinfection

hen all states fully reopen, long-term care facilities (LTCFs) must balance the needs of residents against the potential for additional deadly COVID-19 outbreaks. COVID-19 uncovered deep flaws in nursing homes that have been worsening for decades. Nursing home is a generic term for a facility for a patient who can no longer remain at home because they require 24-hour nursing care and monitoring, also known as a skilled nursing facility (SNF), long-term care facility (LTCF), or extended care facility (ECF).

 For this article, LTCF will be used to refer to these 3 types of facilities.

Seventy percent of LTCFs are for-profit operations, a factor that’s been linked to the spread of COVID-19.

 Unlike hospitals, most LTCF residents live in these facilities permanently, although some are admitted for shorter periods of rehabilitation after a hospital stay. Although these facilities are designed to be comfortable for long-term emotional, social, and physical well-being, they also are perfect incubators for viruses and bacteria. Their layouts increase person-to-person contact. Most residents share bedrooms, bathrooms, activity rooms, and dining rooms—and staff usually share a break room. Although group spaces encourage socializing and are designed partly to cut costs, they also help spread infectious diseases.

 Residents are generally older, frail, and often have comorbidities that make them more susceptible to severe infections such as COVID-19. Many need help performing basic activities of daily living such as eating, dressing, or bathing, increasing the chances of being infected by the staff who help them or passing the virus along to their caregivers.

When mortality rates at facilities struck by COVID-19 were compared with ones that were spared, the more the virus spread through a facility, the greater the number of deaths recorded for 

. In facilities where at least 30% of residents had the virus, the rate of death for reasons 

 the virus was double what would be expected without a pandemic. This implies that the care of those who didn’t contract the virus may have been negatively affected as the staff were overwhelmed attending to residents with COVID-19 or were left short-handed as employees became infected.

Many LTCFs lack the necessary resources to protect seniors from COVID-19. News articles describe LTCF staff as generally underpaid, often living in crowded conditions at home, traveling on public transportation, and working jobs in multiple homes to make ends meet.

 Statements from staff and administrators mentioned that staff feared exposure to COVID-19 and other infectious diseases, along with fear of bringing home infections to their family members; some lacked accessible child care; some had competing family obligations. Many staff don’t receive health insurance or paid sick leave, leading some to work even when they are experiencing symptoms. The facilities they work in may have insufficient personal protective equipment (PPE) and training on how to use it. Many facilities lack COVID-19 testing for staff and residents.

The other issues that make LTCFs so vulnerable—chronic underfinancing, inadequate clinical services, and fragile staffing—seem to be endemic to the LTCF industry. Before COVID-19, this sector endured widespread economic and operational problems. Since the initial COVID-19 surge, LTCFs have lost occupancy and utilization, have lower revenues, and face immense staff retention and recruitment obstacles.

Public opinion on LTCFs has been further eroded by the human toll from the pandemic. According to AARP, “the American nursing home industry exists as it does today because of federal laws and regulations that go back 85 years. The infrastructure these laws created, no matter how well intended, didn’t anticipate the future, nor could it foresee a health storm of this magnitude, speed, and deadliness.”

The Centers for Medicare & Medicaid Services (CMS), an agency within the US Department of Health and Human Services (HHS), is responsible for ensuring the approximately 15,500 LTCFs, with 1.4 million residents nationwide, meet federal quality standards.

LTCFs must meet standards to protect residents. These standards were 

Hiring enough quality staff to provide adequate care

Protecting residents from physical and mental abuse

Establishing and maintaining an infection prevention and control program.

Under the CMS umbrella, state survey agencies are expected to conduct inspections once a year and can inspect facilities more often if the facility is performing poorly or if there are complaints or facility reported incidents. Inspectors also review the residents’ clinical records and interview residents, family members, caregivers, and administrative staff. The inspection team looks at many aspects of life in the LTCF including as follows:

The care of residents and the processes used to give that care

The infection prevention and control program

Infection control inspections are an abbreviated type of inspection that allow the team to focus specifically on LTCF infection control policies and practices. These inspections can identify serious risks to resident health and safety through the spread of communicable disease. They review areas such as:

Performance of hand hygiene including hand washing and the use of alcohol-based hand sanitizers

Staff education, monitoring and screening for infection control

Appropriate cleaning and disinfection of surfaces

Not surprisingly, infection prevention and control deficiencies were the most common type of deficiency cited in surveyed facilities, with most facilities having an infection prevention and control deficiency cited in 1 or more years prior to the pandemic. Infection prevention and control deficiencies can include items such as staff not regularly using proper hand hygiene or failure to implement preventive measures during an infectious disease outbreak. Isolating sick residents and using masks and other PPE are critical to preventing the spread of infectious diseases from multidrug-resistant organisms and respiratory viruses.

A US Government Accountability Office report found that from 2013 through 2017, 82% of all surveyed LTCFs were cited. In each individual year, approximately 40% of surveyed LTCFs had infection prevention and control deficiencies, which continued in 2018 and 2019. Approximately half (48%) of LTCFs with an infection prevention and control deficiency had this same deficiency cited in multiple consecutive years from 2013 through 2017.

 This indicates persistent problems that existed long before the onset of the pandemic. The safety of the residents, who often are in frail health and live in close proximity to one another, was brought to the attention of the world during the COVID-19 pandemic.

Most critics of the LTCF industry agree that it was dealt a nearly impossible hand during the pandemic, left to take the brunt of public anger over the large number of deaths at LTCF facilities. The American Health Care Association, a not-for-profit federation of affiliated state health organizations that represents more than 14,000 not-for-profit and for-profit LTCFs, states that “the failure of public health services at all levels to prioritize [long-term care facilities] for both testing and personal protective equipment left the industry unequipped to stop the spread of the virus.”

But there are some data that show a link between LTCF quality and COVID-19 cases. Investigators found that facilities that had lower quality ratings from regulators before the pandemic were more likely to have outbreaks.

 And the New York Times found that residents in top-rated facilities were as likely to die from COVID-19 as those in facilities ranked near the bottom.

LTCFs do have protocols to handle outbreaks such as influenza, but the COVID-19 pandemic arrived so quickly and the SARS-CoV-2 virus was so contagious that many facilities were caught unprepared. The reasons vary from state to state and facility to facility. In general, when SARS-CoV-2 reared its head, many LTCFs did not have enough PPE on hand or adequate staff trained to use it to sustain the volume of patients with COVID-19.

They couldn’t institute mandatory use of PPE for staff in order to protect them or offer PPE to visitors. They couldn’t provide testing for staff and residents to help them and their families make good decisions regarding working ill and visitation. Instead, hospitals were prioritized over LTCFs in terms of emergency assistance, even though elderly adults and individuals with disabilities, who make up the vast majority of LTCF residents, are at highest risk for serious illness and death from COVID-19.

An article by the John A. Hartford Foundation sums up how some view LTCFs: “Unfortunately, the situation in LTC [long-term care] with COVID-19 is consistent with how America treats LTC. We prefer these essential facilities and their residents and staff to be out of sight and out of mind. We place the sickest, frailest, and most vulnerable people in 1 spot and then pay less than minimum wage to those who will be caring for them, despite the difficult nature of their jobs. LTCF staff provide care for many individuals who have profound dementia, complex chronic diseases, and decreasing function and ability to eat, bathe, or move around on their own.”

The COVID-19 pandemic emphasized LTCF patient and staff safety and infection control practices as critical public health issues. The impact of the pandemic on residents and staff in LTCFs called for reexamining the relationship between the physical environment and the factors of infection control, quality of life, and overall resident and staff safety.

 Yet even now these facilities continue to be a major source of US COVID-19 cases.

Investigators at UCLA and Yale University found that LTCF aides who worked in multiple facilities in order to make more money contributed to the spread of COVID-19. They found restricting workers to a single facility had the potential to reduce COVID-19 infections by 44%.

An LTCF aide can be responsible for more than 20 residents on a shift. The job is physically and emotionally demanding, and the average wage is approximately $13 an hour. Requirements for the job vary by state. In most states, workers complete a hands-on training course and a certified nursing assistant (CNA) program, which is approximately 75 hours of training over 3 months. Surprisingly, state requirements to gain a hairstylist license are more demanding than those for a CNA, says Lori Porter, cofounder and CEO of the National Association of Health Care Assistants.

 Now that COVID-19 restrictions have limited CNAs to working at just 1 facility, many are now unable to afford basic living expenses. Without increased pay and benefits, coupled with the mandated vaccine, LTCFs will remain short-staffed.

Cell phones, tablets, and other videoconferencing devices have been invaluable in helping reduce isolation and loneliness in LTCFs. Virtual visits were linked to a 50% lower risk of depression compared with emails, social media, or instant messaging.

“Social isolation was a mental and physical health problem in nursing homes long before COVID-19,” says Bei Wu, PhD, director for research at the Hartford Institute for Geriatric Nursing at New York University. Lack of connection is associated with a 50% higher risk of dementia, 29% higher risk of coronary heart disease events, and a 32% higher risk of stroke.

Physical contact is also important. The creation of spaces where LTCF residents and family members could meet and hug demonstrated the importance of incorporating safe areas for in-person visits. These are spaces made out of plastic sheeting with holes cut into it to allow protected physical contact. Moving forward, there could be plexiglass walls, a sound system, antimicrobial surfaces, and perhaps a “hug wall” made of flexible material for germ-free embraces.

Telehealth increases patient engagement, reduces costs, and saves time. Telehealth enables patients to be more engaged in their own health and well-being. During the pandemic, Medicare authorized payment for telehealth services to residents in any health care facility and in their home.

 Clinicians who were able to virtually assess LTCF residents via video monitoring were more likely to catch health issues sooner and then treat patients where they were, rather than having to admit or readmit them to a hospital. Avoiding unnecessary trips to the hospital can promote better health outcomes for patients and benefit LTCFs by reducing lost revenue when a patient is in the hospital. Clinicians were better able to assess and provide care while avoiding risk of exposure to SARs-CoV-2.

LTCFs that had the resources and staffing to anticipate and prepare for the pandemic fared much better than those that didn’t. These facilities shared what they learned: Stock up on cleaners, disinfectants, and PPE and masks for workers and residents; screen everyone who walks in the door for symptoms; hire more staff to clean bathrooms and common areas; educate everyone on best practices for containing the virus—wash hands, avoid close contact, keep an eye out for fever or cough; lock down the facility and isolate infected residents.

Having an infection preventionist on site or as a consultant to lead infection prevention and control training makes a difference. The ability to screen, isolate, or group patients can save lives. Ongoing testing of residents and staff is critical, as is vaccination of residents and staff to keep the virus under control.

LTCFs should stockpile PPE, not just for COVID-19 but also for other contagious events. Even more safety improvements and changes may be necessary. Not just because another pandemic may be around the corner, but because the aging US population demands them to stay independent and safe. By 2030, every baby boomer will be at least 65 years old, with Generation X and the millennials aging right behind them.

Although infection prevention is a critical component for patient and staff safety, critics think the LTCF system needs attention beyond what infection prevention practices can provide. It may be time to rethink what LTCFs should look like based on what was learned from the pandemic. Too often, LTCFs look, feel, and function like hospitals. Besides looking at creating smaller LTCFs, familylike household facilities may be a better option.

“Making nursing homes the de facto choice for older Americans in need of care set the stage for the ravages of the pandemic,” says Patricia McGinnis, JD, executive director of California Advocates for Nursing Home Reform. “LTCFs are not good places for anyone except for short-term rehab. I would hope this is a wake-up call that the system isn’t working.”

Advocates for alternatives to LTCFs include AARP and the Green House Project. AARP, a nonprofit, nonpartisan organization dedicated to helping older Americans achieve lives of independence, dignity, and purpose, has more than 33 million members.

 They have been outspoken on behalf of their members, urging LTCF reform.

The Green House Project is an innovative, nationally recognized model in LTCFs that creates small homes that recognize the individuality of residents and respect their autonomy, choice, privacy, and dignity, yet are also affordable. Founded in 2003, the Greenhouse model has key features that provide infection mitigation, including private rooms, more access to outdoor spaces, open floor plans that allow for social distancing, and a staffing model that limits the number of people with whom each resident interacts.

 There are approximately 300 Green Houses in 32 states. These homes house only 10 to 12 residents that live in a housing center and share an open kitchen, dining room, and living room. Specially trained CNAs work exclusively in 1 house—making meals, doing laundry, socializing, helping residents pursue their interests, and looking for early signs of health issues.

“All the features that make them a great place to live also make infection prevention and control easier,” according to Susan Ryan, senior director of the Green House Project. Both of these organizations believe few individuals would choose to live in LTCFs if there were more viable options to allow them to stay at home. Under Medicaid law, states are required to pay for nursing home care for anyone who qualifies. States are not required to pay for the home- and community-based services that would help seniors stay in their homes. This is why LTCFs have become the default for many.

AARP representatives met with more than 36 experts.

 Here are some additional suggestions for change that came out of the meeting:

LTCFs with higher staffing levels of registered nurses (RNs) did better at controlling SARs-CoV-2 and reducing death, according to results from a study at the University of Rochester Medical Center. Facilities with at least 1 positive COVID-19 case had a 22% decline in cases for every additional 20 minutes of nursing coverage, the results showed. But federal laws and regulations only require LTCFs to employ an RN for 8 consecutive hours a day, leaving 16 hours with no RN coverage. Federal law also allows states to grant waivers to LTCFs that can’t meet the regulations even though regulations for RN staffing were put in place as part of the Nursing Home Reform Act of 1987. The legislation was in response to a congressional study that found that many Americans were receiving poor medical attention in LTCFs and that some experienced neglect and abuse. More than 30 years later, this is still an issue.

During the pandemic, some hospitals began working with LTCFs to provide testing and expertise on infection control and use of PPE. This type of partnership helped prevent major outbreaks in LTCFs that would have overwhelmed emergency departments.

Unless funding for home- and community-based services is substantially and steadily increased over the next several years, the failures of the current LTCF system will worsen. The US spends less of its GDP (1%) on LTCFs than virtually every other wealthy country. Moving to a higher level of GDP spending on LTCF services would enable expansion and improve access to community-based programs and make it possible to pay care workers a livable wage, health care benefits, and sick leave. There would be funds for transitioning from the traditional nursing home of 100 beds or more to a smaller, homelike, individualized care facility.


On paper, the rules and regulations for operating safe LTCFs are detailed and strict. However, advocates for LTCF residents say that they are not strictly enforced. Sen. Bob Casey (D, Pennsylvania), who is chairman of the Special Committee on Aging, says that COVID-19 has “supercharged” the need to root out nursing homes that are failing residents. Casey and Sen. Pat Toomey (R, Pennsylvania) introduced legislation, also supported by AARP, that aims to hold nursing homes more accountable.

Approximately 70% of nursing homes are for-profit entities, and many are part of large, complex, and often opaque organizations. Ending the for-profit ownership model that dominates the industry—especially the private-equity investment model of flipping properties for big, fast returns—could possibly help.

So what’s changed since COVID-19 arrived and took the lives of more than 186,000 residents and staff at LTCFs as of December 2021? The pandemic emphasized the need to better prepare LTCFs for future outbreaks, especially in facilities that are home to an older, more frail population. The federal government has taken some actions. It is requiring LTCFs to self-report COVID-19 cases and deaths at the federal level, order testing, provide limited PPE and other resources to LTCFs, establish requirements for education on vaccines, offer COVID-19 vaccines to residents and staff, report LTCF resident and staff vaccination status, and require LTCF staff vaccinations.

Renewed awareness has brought more government and regulatory oversight. Better wages, working conditions, and benefits for LTCF staff are being discussed. More innovative thinking, such as virtual family visits, “hug” rooms, facility design, and telehealth/telemedicine, is in the works. The staff and leaders of LTCFs, and the 1.5 million people they care for, deserve Americans’ attention and action to make it through this evolving crisis and look to a future where this loss of life will never happen again.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago, Illinois. She is also a member of the Infection Control Today® Editorial Advisory Board.

AARP is one of the organizations monitoring how long-term care facilities (LTCFs) weather the COVID-19 pandemic. LTCFs have been particularly hard hit by SARS-CoV-2. Of the approximately 780,000 individuals in the United States who died from COVID-19 as of early December 2021, approximately 186,000 (nearly 24%) were residents and staff at LTCFs. Deaths at LTCFs were declining as of December 2021. Unfortunately for the already understaffed LTCFs, staffing shortages were on the rise.

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Having an infection preventionist on site or as a consultant to lead infection prevention and control training makes a difference. The ability to screen, isolate, or group patients can save lives. Ongoing testing of residents and staff is critical.

Changes COVID-19 Brought to Long-Term Care Facilities

No one should ever have to fight for their health over an infection they didn’t have when they entered a health care facility. Health care procedures can leave a patient vulnerable to microorganisms, such as bacteria, fungus, or viruses, that can cause health care–acquired infections (HAIs). HAIs are infections people get while receiving health care for another condition. They are defined as “infections not present and without evidence of incubation at the time of admission to a health care setting.”

Infection preventionists (IPs) don’t provide any hands-on patient care, but they should be knowledgeable on current best practices for that care. Detailed knowledge of practices and processes for insertion/maintenance of medical devices, instrument reprocessing, and cleaning and disinfection—to name a few—are critical. This is how IPs know what they are doing when they observe practices so they can assess whether there are any gaps and provide education and training, if needed, to help drive down HAIs. IPs don’t have to do this alone. Infection prevention and control is a team sport. When IPs share what they know with other health care personnel (HCP), they are helping to build their team of knowledgeable participants. HAI reduction needs to be on the minds of everyone who touches a patient. IPs can be the coaches to lead the way. IPs don’t have to start from scratch with resources to share with HCP because the Centers for Disease Control and Prevention (CDC) has a done the work for IPs, providing a good starting point that IPs can use as is or tweak to fit their facility and its needs.

HAIs can spread in health care settings from patient to patient via the unclean hands of HCP, unclean equipment, improper use or reuse of equipment, or they can be associated with the devices used in medical or surgical procedures. They can be localized or systemic and involve any system of the body. They can happen in any health care facility—hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities—making them a huge concern in health care. They have serious emotional and medical consequences and are a significant cause of illness and death.

The CDC estimates that on any given day, 1 in 31 hospital patients and 1 in 43 nursing home residents have an HAI.

 According to CDC data from 2020, there are about 1.7 million infections and 99,000 associated deaths each year.

 If the number of infections or death toll didn’t raise an eyebrow, maybe this will: HAIs cost the US health care system about $96 billion to $147 billion annually.4 Nevertheless, these infections are considered preventable.

In order of occurrence, the most common types of HAIs are catheter-associated urinary tract infection (CAUTI) at 32%; surgical site infection (SSI) at 22%; ventilator-associated pneumonia at 15%; and central-line associated bloodstream infection (CLABSI) at 14%.

HAIs are commonly caused by antibiotic-resistant bacteria, which can lead to sepsis or death. One in 7 catheter- and surgery-related HAIs in acute care hospitals and 1 in 4 catheter- and surgery-related HAIs in long-term acute care hospitals are caused by any of 6 antibiotic-resistant bacteria (not including 

). These 6 bacteria are among the deadliest antibiotic-resistant bacteria, identified as urgent or serious threats by the CDC: carbapenem-resistant 

 (ESBL-producing Enterobacterales), vancomycin-resistant 

Unfortunately, the number of multidrug-resistant organisms (MDROs) continue to increase, raising worldwide concern.

Hospital-based programs of surveillance, prevention, and control of HAIs have been in place since the 1950s

—yes, you read that correctly, over 70 years—and we keep developing new strategies with new names, slowly making progress. The Study on the Efficacy of Nosocomial Infection Control Project from the 1970s showed nosocomial rates could be reduced by 32% if infection surveillance was coupled with appropriate infection control programs. In 2005, the National Healthcare Safety Network was established with the purpose of integrating and succeeding the previous surveillance systems at the CDC: National Nosocomial Infections Surveillance System, Dialysis Surveillance Network, and National Surveillance System for Healthcare Workers. In 2008, the US Department of Health and Human Services (HHS) identified the reduction of HAIs as an “agency priority goal.”

 HHS committed to reducing the national rate of HAIs, creating the 2009 National Action Plan to Prevent Health Care–Associated Infections: Road Map to Elimination, released in April 2013.

 This HAI Action Plan provided a road map for preventing HAIs in acute care hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities, and for implementing antibiotic stewardship efforts as a method of HAI prevention. The HAI Action Plan also included a chapter on increasing influenza coverage of HCP, which was long overdue.

This HAI Action Plan was updated again in 2016, with new targets for the national acute care hospital metrics data from 2015 as a baseline, which were in effect 2015 to 2020. These new targets replaced the previous targets that expired in December 2013. The new target 2016 HAI Action Plan goals, which HHS states are “ambitious, but achievable” for reduction of HAIs include the following

reduce CLABSI in intensive care units and ward-located patients

reduce CAUTI in intensive care units and ward-located patients

reduce the incidence of invasive MRSA HAIs

reduce hospital-onset MRSA bloodstream infections

The CDC website has a section called “Infection Control Assessment Tools

” under its HAI section that constitute the basic elements of an infection prevention program designed to prevent the spread of infection in different health care settings. These assessment tools are broken down by type of health care setting—acute care (including long-term acute care), long-term care, outpatient, hemodialysis, and oncology. Each assessment tool for the different health care settings is a bit different because different health care settings have different populations, practices, and procedures. When these basic elements are part of an infection prevention and control program and are practiced consistently—with consistency being key—the risk of infection among patients and HCP is reduced.

The assessment tools break down infection prevention practices into domains of practice, such as hand hygiene (HH), PPE, instrument reprocessing, and SSI prevention, where a templated set of questions can be used to perform a gap analysis to determine training, competencies, policies, and procedures. IPs should be familiar with these and use them, as they are readily available so they don’t have to reinvent them. In addition to these assessment tools, there are others under the CDC’s “Preventing Healthcare-Associated Infections” section9 that IPs should at least review or know if they cover any of these specific settings:

 is a method to ensure urine cultures are performed only when appropriate indications are present to determine whether treatment with antibiotics is indicated—think catheter-associated asymptomatic 

 vs CAUTI. This section includes diagnosis and treatment guidelines from the Infectious Diseases Society of America.

 Institutions that have implemented urine culture stewardship programs have reported a decreased number of total urine cultures ordered, inappropriately treated ASB cases, costs related to overtreatment of ASB, and CAUTIs.10 Because CAUTIs are the No. 1 HAI (32%), IPs should provide education on the importance of this program because it works.

The targeted assessment for prevention strategy

 uses voluntarily submitted data from facilities or targeted units that may be struggling with HAIs. It includes an assessment of gaps in HAI prevention and can recommend opportunities for improvement from the experts at the CDC. Single-person IP departments struggling to get ahead of HAIs might wish to consider contacting the CDC for help.

 have resources to assist clinicians, administrators, and health department personnel with preventing infections in nursing homes, assisted living facilities, and other long-term care facilities. There are tool kits for dialysis, acute care MDRO control, environmental infection prevention for surfaces and water, CRE, norovirus, vancomycin-resistant 

, and CLABSI. An example of 1 nice resource in this tool kit is a very detailed inter-facility transfer form with patient-specific details, such as MDRO history, devices present, transmission-based precautions status, antibiotic usage, vaccination status, and sending/receiving facility contact information. All valuable information for the IP and receiving unit.

Basic infection control and prevention plan for outpatient oncology settings

 is an amazing section that should be titled “Everything an IP Needs to Know for An Oncology Setting.” It covers the basics from HH and PPE to access and maintenance of long-term central venous catheters, and safe injection practices, with recommendations adapted directly from the Access Device Standards of Practice for Oncology Nursing and the Infusion Therapy Standard of Practice.

These are must-reads for IPs in this area.

Guide to infection prevention for outpatient settings: Minimum expectations for safe care

 is a summary guide of infection prevention recommendations for outpatient (ambulatory care) settings based on existing evidence-based guidelines from the CDC and the Healthcare Infection Control Practices Advisory Committee. It emphasizes the importance of standard precautions as the foundation for preventing transmission of infectious agents during patient care in all health care settings. It also speaks to HH, PPE, environmental cleaning, disease surveillance, respiratory etiquette, and injection safety, and it has a nice checklist to help with auditing an outpatient facility. It also has links to full guidelines and source documents for more details—1-stop shopping for IPs who cover this setting.

 promotes patient safety through improved use of PPE by HCP. It has PowerPoint slides and posters on how to select PPE to limit the spread of contamination. It is a ready-made training document that can be shared with all HCP.

IPs should work to create a team of highly engaged HCPs. They should educate and encourage the use of guidelines and tools that increase widespread adoption of best practices to prevent infections, such as the CDC resources and tools outlined above. IP-led infection control and prevention education and training to HCP should focus on proven methods to prevent HAIs:

appropriate and timely transmission-based precautions

cleaning and disinfection of environment/medical equipment and devices

decolonization and antibiotic stewardship programs

Remember, teams are usually built 1 member at a time, and not all members have the same strengths or beliefs. If available, recognize staff members or units that have worked hard to prevent central line infections and try to recruit them first. They have experience with success and would probably like to be on an IP’s team to share what they know. Or an IP can start with the basics so they can build a strong foundation for team member buy-in

Make sure HCP understand the importance of HH, transmission-based precautions and environmental/device cleaning and disinfection practices.

Educate on the CDC guidelines for preventing infections using those prevention bundles.

Promote data use to target prevention and improvements.

and infections that can occur after surgery or that are related to single-use catheters.

Educate on why IPs isolate patients and when it’s appropriate to discontinue.

Educate on antibiotics, including the importance of antibiotic-resistance patterns in a facility/area to improve antibiotic use; why prescribing antibiotics correctly is important; the role culturing plays in starting antibiotics promptly, reassessing 24 to 48 hours later, and when to stop antibiotic treatment.

IPs should not forget to include patients and their families as part of the team. Empower them by educating them on questions to ask regarding their care: 

If they have a catheter, ask daily whether it’s necessary.

If they are having surgery, ask their doctor how they prevent infections.

Insist that everyone clean their hands before touching them and to clean their own hands often.

Insist that everyone who enters their room wear PPE if it’s required.

Ask what their antibiotic is for and whether it is necessary.

The knowledge, tools, and resources are now available for organizations to make major progress in reducing rates of HAIs in their facilities. IPs should start building their teams to win the battle against HAIs.

Custodio HT. Hospital-acquired infections. 

. Updated October 21, 2021. Accessed October 6, 2021. 

https://emedicine.medscape.com/article/967022-overview#a5

HAI and antibiotic use prevalence survey. Centers for Disease Control and Prevention. Accessed October 6, 2021. 

https://www.cdc.gov/hai/eip/antibiotic-use.html

Healthcare-acquired infections (HAIs). Patient CareLink. Accessed October 6, 2021. 

https://www.patientcarelink.org/improving-patient-care/healthcare-acquired-infections-hais/

Marchetti A, Rossiter R. Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. 

. 2013;16(12):1399-1404. doi.org/10.3111/13696998.2013.842922

https://www.cdc.gov/vitalsigns/pdf/2016-03-vitalsigns.pdf

Healthcare-associated infections. US Department of Health and Human Services. Accessed October 7, 2021. 

https://health.gov/our-work/national-health-initiatives/health-care-quality/health-care-associated-infections

In order of occurrence, the most common types of HAIs are catheter-associated urinary tract infection (CAUTI) at 32%; surgical site infection (SSI) at 22%; pneumonia (ventilator-associated pneumonia) at 15%; and central-line associated bloodstream infection (CLABSI) at 14%.

By Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC

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