Linda Spaulding, RN, BC, CIC, CHEC, CHOP

I was recently asked whether I think coronavirus disease 2019 (COVID-19) will change regulations within long-term care facilities (LTCFs)LTCFs). I decided I wanted to look at it from the perspective of what went wrong in the utilization of current US Centers for Medicare and Medicaid Services (CMS) regulations. The current regulations are written in a way where, on paper, the regulations are easy to survey, but what is missing is the ability to ensure LTCFs have a strong infrastructure that supports infection prevention and control success in the LTC arena. 

First, I decided to see what is happening across the United States related to outbreaks of COVID- 19 in the nursing homes. I have been working as an infection prevention and control consultant for LTCFs and other healthcare arenas since 1992. I would have predicted that LTCFs would be on the losing end of COVID-19 if someone did not step in early to educate and assist these facilities. LTCFs could not handle this type of a communicable disease on their own. 

Some may not have believed COVID-19 was a big deal and they could handle it like they do influenza. Others may have not wanted an outsider to suggest they do something different from how they always do things. Some people don’t like change and may not have been able to wrap their head around the extreme changes they would have to make to deal with this type of a pandemic. 

Recent publications are reporting the elderly are more likely to experience severe complications stemming from COVID-19 infection. We have known this from the beginning of the pandemic, but it does not appear that anyone was proactive enough when it came to concentrating on how LTCFs could deal with an outbreak. Did they have enough staff? Did anyone reach out to assess LTCFs needs related to staffing, personal protective equipment (PPE), or disinfectants? Many outbreaks were happening in LTCFs before anyone was paying attention to them. 

According to the National Center for Health Statistics there are more than 1.3 million residents in nursing homes; 811,500 residents living in res- idential care communities such as assisted living and intermediate care facilities and an estimated 1.5 million individuals are employed in these facilities.

 CMS released guidelines to reduce the effect of COVID-19 on these types of facilities. This guidance included visitor restrictions, infection control guidelines, and designating separate areas for those who were diagnosed with COVID-19. 

But it fell short of the federal requirements to report COVID-19 outbreaks. Only during the week of April 19 did information start being released to the general public regarding how nursing homes have been affected by COVID-19. 

reports at least 2300 nursing homes have reported cases of COVID-19. The impact on nursing homes is far greater than what is being reported by the federal government. 

 reports that 37 of the 50 states have reported cases of COVID-19 and more than 3000 deaths among long-term care residents. It has been reported that neither the US Centers for Disease Control and Prevention (CDC) nor CMS were tracking the number of US nursing homes with COVID-19 cases. The case fatality rates are also not being tracked. Reports have shown when states such as Florida were asked for data they did not respond. Florida is known for its high number of elderly residents, as well as millions of seasonal visitors during the winter months. These millions of visitors typically return to their home states in April. If they have become colonized or are sick with COVID-19, they will take it back to their home states and more outbreaks will continue. Thirteen states could only provide partial data and could not differ- entiate residents infected or staff infected. 

Even during non-pandemic times, many nursing homes across the country have received infection control citations. 

Healthcare workers in LTCFs deserve to have honest communications from their administrators so they can also protect themselves and their families. Like acute care facilities, LTCFs need help obtaining PPE. Many LTCFs and assisted living facilities are privately owned. Is this the reason reporting is lacking with this group of LTCFs? 

On April 19, 2020, 4 months after the pandemic began, CMS released guidance requiring nursing homes to report cases of COVID-19 to the CDC. The death rate that have been reported as of April 23, 2020: More than 10,000 residents and staff died because of COVID-19. Yet very few states are being proactive in testing all residents and staff in these facilities. Many hospitals haven’t had access to testing. How would LTCFs get access without states stepping in and providing the support? 

CMS requires that all LTCFs must follow accepted national standards. The infection prevention and control program (IPC) shall include at a minimum:

·       A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.

·       Written standards, policies, and procedures for the IPCP, including but not limited to a system of surveillance designed to identify possible communicable disease or infection before it can spread to other persons in the facility; reporting requirements for possible incidents of communicable disease or infection; standard and transmission-based precautions to be followed to prevent spread of infection; circumstances in which generally, isolation should be used for a resident; the circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if the contact is likely to transmit the disease; and the hand hygiene procedures to be followed by all staff as indicated by accepted professional practice. 

·       Require that the facility designate an Infection Prevention and Control Officer (IPCO) who is responsible for the IPCP and who has received specialized training in infection prevention and control.

The above is just the section of the CMS regulations that should have been used during the COVID-19 pandemic. Many LTCFs have interpreted the require- ment for them to have an IPCO, as this person must be a permanent hire and it excludes them from relying on an expe- rienced infection prevention consultant who can provide mentoring, training and advice to an inexperienced IPCO. 

The requirement for IPCO training was basic training related to infection prevention, but it was lacking any mea- sures for determining competence of the IPCO. The area lacking in LTCF regulations is the issue of the inexperience of the facilities’ IPCO related to understanding how to identify infection issues. 

Some facilities lack administrative sup- port for a good understanding of what to do when infection prevention issues arise yet if asked, they will state they know everything about infection prevention and do not need help, lacking the insight that infection prevention is more involved than just the basic knowledge of washing your hands and putting PPE on. 

Sick-call policies in many healthcare arenas are based on disciplining employees who call off sick requiring a physician note to return to work. Many times, employees can obtain a physician note to return to work before they are cleared of a commu- nicable infection. In some cases healthcare settings as well as LTCFs have let staff work with respiratory tract infections because of limited staff or an inability to pay overtime. This practice has been linked to flu outbreaks every year. It’s unfortunate that this time it was not the flu, but in the case of COVID-19 which, if practices are reviewed when the pandemic is under control, some of these LTCF outbreaks were due to letting employees work sick because of poor staffing. Also in play was the inexperience of the facilities’ IPCO to be able to identify an outbreak of COVID-19 or because of lack of testing of healthcare workers (HCWs) who were asymptomatic carriers. 

Many IPCOs are assigned multiple tasks such as wound care, director of nursing, unit charge nurse, or unit super- visor, which can interfere with performing proper infection prevention and control. Many facilities cannot get physicians to see residents in LTCFs because they do not get reimbursed enough to make it worth their time. Pay in some LTCFs is also exceptionally low and does not match the quality of nursing care seen in acute care facilities. 

Many healthcare facilities, not only LTCFs, have turned to online training for staff and then designate the employee as competent to do their job. Online training does not prove competency; it provides training. The survey process does not look at competency of staff, it looks to ensure all employees have completed their annual training require- ments for infection prevention. There is no measurement of competency. Many employees in LTCFs are task-orientated individuals who work extremely hard and long hours and will do as they are instructed. If the person instructing them does not identify when there is an outbreak of any disease, whether flu or COVID-19, and provide clear instructions with follow-up with those employees that what was being requested was actually done, there will continue to be breaks in infection prevention practices. 

Many CMS surveyors have basic training in infection prevention but they also have limited experience doing infection prevention and it is easy to miss where infection prevention breaks are that enable facilities to identify when they have a problem before it gets to be a big issue. 

As for the COVID-19 pandemic and what is happening in LTCFs-many were destined to fail at infection prevention. Because much of the focus was on hospitals in need of PPE and ventilators, no one was checking in on LTCFs and determining what their needs were. Many LTCF staff did not show up for work. LTCFs that did try to get disinfectants and PPE were last on the list because acute care took priority. 

Many LTCFs work with one vendor to obtain their PPE and facility disinfectants. If their vendor does not have what they need or decides to sell to acute care first because they can sell to acute care at a higher rate, then LTCFs lose out. Many do not know what other companies they can buy supplies from. 

So where do we go from here to make sure LTCFs are set up for success in the future? I believe there needs to be a thorough assessment of all LTCFs in each state after this pandemic to identify answers to many questions and identify what is needed to set them up for success. COVID-19 is our influenza pandemic of 1918. What haven’t we learned and what do we need to do now to be ready the next time there is a pandemic? How are we going to deal with the next round of COVID-19? 

My suggestion is each state needs to retrieve data from all LTCFs:

·       When did the facility go into lockdown?

·       When did the facility start putting in orders for more PPE and disinfectants?

·       Who and how many vendors did they contract with?

·       What education was given to the employees and when did that education happen? Reviewing exactly what education information was provided.

·       When did staff start wearing masks?

·       How often were masks changed?

·       What was the first date that an employee or resident became sick?

·       What was the first date that the facility considered they had a problem with COVID?

·       When did the facility reach out for help?  

·       Who did they ask help from?

·       What response did they get when they asked for help or reported illness within their facility?

·       How many staff did not come to work because of fear?

·       Did the facility have access to a physician or physicians coming into the facility to help manage and prepare for COVID-19?

·       Did the facility reach out to the local hospitals?

·       Did anyone reach out to LTCF and if so, what happen?

Did they reach out to anyone to ask to transfer their residents and were refused?

·       When did they notify their local department of health to ask for help with sick residents or to obtain PPE and disinfectants?

·       Did they reach out to local emergency preparedness agency?

·       Do they qualify for federal or state help if they are privately owned?

The answers to these questions and many more could help build stronger infection prevention programs within LTCFs as well as trouble shoot problem areas not identified before the pandemic, so they are set up for success. Is the elderly in the US seen as an important part of the community or are they vulnerable because they are ignored and left to die during a pandemic? Let us prepare LTCFs for success, but owners of these facilities must want to participate, put up the money, and provide protection for residents and employees. 

Linda Spaulding, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc. 

Articles

Many healthcare facilities, not only LTCFs, have turned to online training for staff and then designate the employee as competent to do their job. Online training does not prove competency; it provides training.

COVID-19 Reveals Fatal Infection Prevention Flaws at Long-Term Care Facilities

Over the last decade, the world has experienced many outbreaks, pandemics and epidemics, from severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) to H1N1 influenza and now COVID-19. Since the symptoms of coronaviruses are similar to that of influenza, it is important to identify outbreaks early, contain them, and prevent person-to-person spread until identification of the cause of the outbreak can be determined. 

Coronaviruses can be found in many animal species including snakes, pangolins, camels, cattle, cats, and bats. It is uncommon for an animal coronavirus to infect people and then keep spreading person-to-person. But over the past decade, we have seen just that: 3 coronaviruses infecting humans and causing ongoing person-to-person transmission. 

In February 2003, there was an epidemic of SARS first reported in Asia. SARS, or SARS-associated coronavirus (SARS-CoV), spread to countries in North America, South America, Europe, and Asia before it was contained. An estimated 192 people were infected/ detected with SARS-CoV in the United States. Since 2004, no further episodes of SARS-CoV infection have been reported any place in the world. 

Next came the coronavirus called Middle East respiratory syndrome (MERS). First reported in Saudi Arabia in 2012, MERS has spread to several countries, including the United States. The largest MERS outbreak took place in South Korea in 2015. 

In May 2014, 2 of 1300 patients tested were diagnosed with MERS-CoV infection in the United States. These 2 people were identified as imported cases from Saudi Arabia. One case was in Indiana and the other was found in Florida. Both infections were thought to have arisen from healthcare workers from Saudi Arabia. Both patients made a full recovery. The US Centers for Disease Control and Prevention (CDC) completed an investigation of household members and the healthcare workers who cared for the 2 MERS cases. They all tested negative for the virus. 

Common human coronaviruses (types NL63, OC43, and HKU1) usually cause respiratory tract illnesses, such as the common cold. At some point in our lives, most of the population will become infected with a human coronavirus. 

Despite advances in medicine, global travel has complicated the ability to control the spread of infectious diseases. Both the 2003 SARS epidemic and the 2009 H1N1 pandemic were spread via air travel. Because of this, all healthcare providers must be aware of and alert to possible emerging diseases and understand how to identify, report, investigate, and contain any outbreak until the cause of the infection can be determined. But what is necessary to control any outbreak situation, whether it is a multidrug-resistant organism, influenza, or a novel virus like COVID-19? 

®, Bill Jarvis, MD, president of the consulting company Jason and Jarvis Associates, shared information about the CDC’s role in outbreak investigations. Whether an outbreak is suspected within or outside of the United States, the CDC can provide the following assistance, if invited: 

·      Trained Epidemic Intelligence Service (EIS) officers can travel onsite to assist with the investigation (in collaboration with local infection control personnel). 

·       Diagnostic specimen or samples of the suspect pathogen can be sent to the CDC’s laboratories for identification, serologic, or genetic testing. In the case of COVID-19, samples sent to the CDC would be processed in appropriate containment areas in the Division of Virology or Special Pathogens/Pathology Laboratories. Once new pathogens, such as COVID-19, are identified, gene sequencing and rapid diagnostic testing can be performed and sent to state and local health departments or even to ministries of health throughout the world. Depending upon the pathogen, the specimen/organism would be directed to the appropriate laboratory (ie, bacterial, fun- gal, viral, protozoan, etc.). A wide variety of specialized laboratories are available. 

·       Once the pathogen is identified, the CDC can then develop both rapid diagnostic tests (gene probes, serologic tests, etc.) and can provide such rapid or other diagnostic test kits both nationally and internationally to assist in the diagnosis, prevention, and control of the pathogen/ outbreak. 

·       In addition, either EIS officers or other members of the Division of Quarantine or taskforce personnel can be assigned to critical areas to assist in the control of the outbreak. With COVID-19, this has been seen by assigning CDC and state health department personnel to logistically important airports to assist in screening passengers for COVID-19 and assisting in the isolation of infected or potentially infected people. 

It is important to understand that the CDC is a non-regulatory US agency (aside from the National Institute for Occupation Safety and Health-NIOSH). Thus, whether the outbreak is located within or outside the United States, the CDC must be invited to assist by the local/state/national government and/ or healthcare facility. The World Health Organization (WHO) also must be invited. 

Possible outbreak situations are usually identified by an astute clinician, infection preventionist, or a clinical laboratory worker. First, a previously unrecognized (COVID-19) or unusual pathogen (MERS), or a pathogen with an unusual antimicrobial susceptibility pattern (vancomycin-resistant 

), or an unusual number of cases of a disease (cluster of plague) are noticed. For example, on a Monday morning, it is reported that 4 patients on 1 unit have developed cold symptoms. By Tuesday morning, the number of individuals sick with cold symptoms numbers 6. The continued increase in patients with the same symptoms should be investigated to determine whether there is a respiratory tract infection (RTI) of some type spreading through the facility. Since many coronavirus infections have the same signs and symptoms, it is important to contain the RTIs until the etiology/pathogen identification can be made. 

It will have to be determined whether it is the common cold, influenza, or possibly COVID-19. It is the responsibility of every medical professional to remain vigilant for early signs of a cluster or outbreak and to report possible outbreaks caused by new or novel pathogens or unusual multidrug-resistant organisms to the appropriate authorities (in many, if not most, states, legislation requires reporting of outbreaks to county and state health departments). For very unusual or novel outbreaks, both the countries’ ministries of health and the WHO and CDC should be notified as promptly as possible. Initial prevention and control (containment) can prevent spread within and outside the country of origin and potentially prevent a larger outbreak or pandemic. 

It is important to track all information using a tracking sheet. A tracking sheet can be adjusted depending on the symptoms identified in each outbreak situation. A well-developed tracking sheet is necessary to analyze all the data that is collected during an outbreak situation. Depending on the situation, the tracking sheet may be small such as for an influenza outbreak or more extensive to track things such as all the rooms a patient had been transferred to or what roommates they may have had, and possibility of exposure. 

Components of a simple tracking sheet include: 

Flu vaccination given y/n (if it’s flu season) 

Symptoms (ie, cold, sore throat, malaise, chills, muscle aches, 

Date hospitalized (if from a nursing home, etc.) 

Developing a tracking sheet makes it easier to systematically collect data, add new data, and analyze the existing data. Data can then be reviewed from any data point. 

1.    Early identification of a suspected outbreak.

3.    Define a case and an outbreak and pre-outbreak period.

4.    Communicate to all healthcare professionals that need to know.

5.    Identify all individuals who meet the case definition (patients and staff).

6.    Determine if the number of “cases” exceeds the background rate (ie, it is an outbreak).

7.    If reportable to local and state agencies, report those concerns. Local and state agencies can aid with case identification, development of investigative approach, prevention and control measures, and assist with specimens. 

8.    Appropriately isolate all individuals who meet the case definition. 

9.    Collect appropriate clinical specimens and save all outbreak-specific isolates from potential “cases.”

10.  Confirm a diagnosis (rule out a pseudo-outbreak).

11.  Be sure proper precautions are in place to contain the outbreak once a diagnosis is confirmed. You may decide to implement proper precaution prior to the diagnosis depending on the situation.

12.  Continue to monitor and control the outbreak in order to prevent future spread.

13.  Develop a line listing of “cases.”

14.  Compare exposures of “cases” to better understand the route of transmission and potential risk factors.

15.  Consider conducting additional epidemiologic studies (ie, case-control or cohort studies).

16.  Consider performing genetic studies of the pathogen (especially if previously unrecognized or unusual).

17.  Institute additional control measures, if needed.

18.  Evaluate the efficacy of the control measures.

19.  When control measures have terminated transmission, declare the outbreak is over.

20.  Communicate to all individuals and agencies involved in the investigation that the outbreak is over.

21.  Prepare your final outbreak investigation report.

22.  Provide the opportunity for a debrief to identify strengths and weaknesses in the investigation. Information should be obtained from all effected staff.

23.  Develop opportunities for improvement and action plans to avoid another outbreak.

Linda Spaulding, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc. 

Author | Linda Spaulding, RN, BC, CIC, CHEC, CHOP

Articles

COVID-19 Reveals Fatal Infection Prevention Flaws at Long-Term Care Facilities

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