nfection preventionists’ (IPs) roles in emergency response efforts historically have been minimal in health care settings. Typically, the emergency response program completes a risk assessment annually, the Hazard Vulnerability Analysis (HVA).

 In these reviews, all hazard risks are ranked according to likelihood of occurrence, severity of impact, and current capabilities to mitigate risks. Natural disasters, manmade disasters, and pandemics were included in the analyses. I believe most health care facilities would have ranked the likelihood of a pandemic as low, severity of a pandemic as high, and the capability to manage a pandemic would vary greatly from facility to facility.

As the heightened sense of awareness faded after the Ebola response in 2014 and 2015,

 the funding that had been assigned because of that outbreak began to dissipate and other priorities overtook efforts to maintain biopreparedness programs. Maintaining a strong program is expensive for health care facilities, and many of those costs are not redeemable through reimbursement from payers or funding from outside resources.

Along those same concerns, infection prevention staff were pulled into the efforts to reduce health care–acquired infections (HAIs) as those metrics became part of the Hospital Value-Based Purchasing Program and directly affected a facility’s payments from the Centers for Medicaid & Medicare Services (CMS).

The COVID-19 pandemic exposed many areas of challenge to broad pandemic response. The first surges showed how quickly personal protective equipment (PPE) supplies could be decimated and testing capabilities stretched thin beyond use. Later surges tested capacity, staffing, treatment development, and resilience of a health care force. Throughout the pandemic, misinformation and disinformation made coordinated efforts even more challenging and perhaps highlighted an unforeseen challenge to biopreparedness programs.

 How can health care providers be prepared to handle the deluge of opinions from nonexperts on responding to a pandemic response that affect the behaviors and choices of patients and staff alike?

Crisis standards of care were developed by the Centers for Disease Control and Prevention in response to the shortages and challenges facing health care.

 These standards are a framework to help facilities determine thresholds for staging out mitigation factors, such as PPE reuse, staffing models, and capacity limits. Based on these existing guidelines, biopreparedness programs can develop local models of crisis standards that act as triggers for next steps or mitigation factors.

As COVID-19 becomes endemic (as of this writing the threat that the Omicron variant poses is still unknown), now is the time for IPs to harness the current attention to biopreparedness and use the momentum to build the foundations for strong local programs that can be sustained through future waves of competing priorities.

The first step is to gather leadership support to establish a formal program, if one doesn’t exist, or the support to formalize the existing program and expand on its capabilities.

 The next step is to conduct a gap analysis to determine what worked well during the COVID-19 response, what innovations were developed that can become standard practice, and what areas are still opportunities for improvement. Existing gap analyses (eg, the High-Consequence Infectious Disease Preparedness Checklist from the Joint Commission) can be used.

 Part of the gap analysis could include a run-through of a scenario to determine what actions to take if a patient with a high-consequence disease (HCD) comes into the emergency department.

Once the gap analysis is completed, the results will guide the next steps. A formal committee or workgroup of multidisciplinary members who are all stakeholders can be established to take on action items specific to each department. A written plan can be the cornerstone of the committee’s work; however, the document must be flexible and able to be molded to any new HCD encountered. Having a response plan that isn’t focused on 1 specific disease type (ie, Ebola or influenza) allows for adaptation to the unknown—such as COVID-19 was at first—and is essential to be able to quickly respond when all the information isn’t known.7 Additionally, the committee and plan must have a multiyear strategy, as the work cannot be expected to be completed quickly if it is to be built into the foundations of the organization.

Once the plan is established and the committee is meeting routinely, the next step is to train frontline staff and build competency within your workforce. Training is essential to ensure all who may encounter patients with an HCD can quickly recognize potential transmission threats and enact appropriate isolation precautions and escalate quickly.

Education plans need to include training current employees and making biopreparedness training part of orientation and onboarding for new staff. Turnover in hospitals always presents challenges to maintaining efforts, so having a plan to include biopreparedness in the clinical orientation process will be key to making it part of the organization’s culture. Along with training staff, training the infection prevention team to build expertise also will create the strong leadership in the program. Free programs, such as those sponsored by the Center for Domestic Preparedness in Anniston, Alabama, are a great option to immerse IPs in biopreparedness with others who want to learn more.

Another way IPs can help sustain biopreparedness efforts is to be a leader in their organization’s safety culture. IPs can take a leadership role in facility initiatives such as High Reliability, Lean Six Sigma Management, and other concepts and work to integrate biopreparedness into those initiatives.

 Early response and recognition and escalating safety concerns all fit into those safety culture concepts and can help sustain biopreparedness.

Information technology infrastructure needs to be supported in infection prevention programs in general, including biopreparedness. Analytics and surveillance programs that detail threat assessments and detect syndromic patterns and trends across states and regions help predict risk and develop countermeasures. Barriers to communication across international and national surveillance systems need to be addressed to improve the public health response. Collaboration in public health efforts is needed to ensure outbreaks are addressed early and information shared to prevent transmission.

Federal government investment into biopreparedness would increase interest and ability for individuals and organizations to obtain funding in areas of infectious disease that are lacking across the country. The Infectious Diseases Society of America recently released a statement supporting one such effort, the BIO Preparedness Workforce Act.

 This act would increase funding and loan repayment for health care professionals who spend at least half of their time working in biopreparedness roles or providing infectious disease care in underserved communities. The act is still pending review in the US Congress but would be a strong show of support for bolstering the workforce in this up-and-coming field.

Mandating biopreparedness also could be part of CMS conditions of participation or accrediting bodies. As was demonstrated with HAI prevention, once money was tied to outcomes, focus improved and more efforts were made to bolster IPs’ capabilities. The same could potentially be done for biopreparedness, including mandating training, drills, and comprehensive high-consequence disease plans for health care facilities.

IPs can work with their local health departments to build links within acute care, long-term care, community health, and public health surveillance. If your local public health jurisdiction has a biosurveillance program, have your organization join and become part of a larger network feeding information into larger national databases. Then those databases need to be able to generate useful information that can quickly be passed to local providers who are seeing patients in clinics and emergency departments to apply clinical assessments based on known risk factors.

As we continue into the second year of COVID-19 response, IPs are at the front line to ensure biopreparedness programs become a priority for their organizations. Collaboration and advocacy efforts can build the foundation at local levels, but for true sustainability, federal and state regulatory bodies need to take notice and ensure biopreparedness programs become a primary issue going forward.

REBECCA LEACH, MPH, BSN, RN, CIC, has been an infection preventionist since 2010 with a background in nursing and epidemiology. Leach, a member of theInfection Control Today® Editorial Advisory Board, works at a health care system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

What are the requirements related to the hazard vulnerability analysis (HVA) for organizations and off-site facilities? The Joint Commission. Updated November 16, 2016. Accessed November 30, 2021. https://www.jointcommission.org/standards/standard-faqs/home-care/emergency-management-em/000001196/

Popescu SV. Preparing for special pathogens: an IP perspective. 

https://www.infectioncontroltoday.com/view/preparing-special-pathogens-ip-perspective

The Hospital Value-Based Purchasing Program. CMS. Updated February 18, 2021. Accessed November 30, 2021. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing

Leach R. How infection preventionists can battle misinformation. 

®. 2021;25(10):32-33. https://www.infectioncontroltoday.com/view/how-infection-preventionists-can-battle-misinformation

Optimizing supply of PPE and other equipment during shortages. CDC. Updated July 16, 2020. Accessed November 8, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/general-optimization-strategies.html

Franco C, Hansen M. The state of biopreparedness: lessons from leaders, proposals for progress. Conference Reports. Center for Biosecurity of UPMC. Accessed November 30, 2021. 

https://www.centerforhealthsecurity.org/our-work/events-archive/2010_state_of_biopreparedness/conf_report.pdf

Popescu S, Leach R, Robinson K. Establishing a pre-COVID-19 hospital biopreparedness initiative. 

The Joint Commission Guide to Risk Assessment, Joint Commission Resources, 2021. The Joint Commission. August 25, 2021. Accessed November 5, 2021. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/aug-25-2021/new-risk-assessment-guide-available-from-jcr/

Atkinson MK, Cagliuso NV Sr, Hick JL, et al. Moving forward from COVID-19: organizational dimensions of effective hospital emergency management. 

 2021;19(5):508-520. doi:10.1089/hs.2021.0115

Center for Domestic Preparedness. Training the best for the worst. FEMA. Accessed November 30, 2021. https://cdp.dhs.gov

High reliability and infection prevention. The Joint Commission. Accessed November 30, 2021. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/high-reliability-and-infection-prevention/

Montella E, Di Cicco MV, Ferraro A, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. 

2017;23(3):530-539. doi:10.1111/jep.12662

IDSA and HIVMA Support BIO Preparedness Workforce Act. IDSA. News release. October 25, 2021. Accessed November 11, 2021. 

https://www.idsociety.org/news--publications-new/articles/2021/idsa-and-hivma-support-bio-preparedness-workforce-act/

Articles

Now is the time for infection preventionists to harness the current attention to biopreparedness and use the momentum to build the foundations for strong local programs that can be sustained through future waves of competing priorities.

Add Biopreparedness to IP Checklist

Infection control has always been a relevant topic in dentistry, but dental practices’ and their patients’ awareness of its importance has increased significantly as a result of the COVID-19 pandemic. Let’s examine infection control practices before and during the pandemic, as well as project what they might look like going forward.

Most dental practices took precautions, and some even adhered to best standards, but many likely did not fully appreciate the purpose and effectiveness of infection control and prevention measures and, as a result, may not have strongly enforced infection control policies. Consider the following:

 This practice was limited or nonexistent. Patients would come into the office, even if they weren’t feeling well, and dental practices were not proactive about educating patients about the risks of coming to an appointment while feeling sick.

 It was not common for dentists to post information about proper hand hygiene or cough etiquette in waiting rooms, although it was suggested by the Centers for Disease Control and Prevention (CDC).

 Patients, some of whom could be suffering from a cold or other virus, were also able to sit close to each other.

It was not uncommon for dental team members to take patient-care items out of their packaging and set up the room in advance of a patient’s arrival. Additionally, dental team members may have been more prone to leaving unused items in open storage containers and on countertops until the next patient arrived.

Dental staff may have worn surgical masks and gowns but rarely, if ever, wore N95 respirators and face shields.

Infection control has always been a state-mandated CE requirement, but many dentists and their team members likely viewed infection control classes as a burden and just 1 of many topics they needed to obtain CE credits.

Once the authorities allowed dental practices to reopen after the onset of the pandemic in 2020, and after it was more understood that COVID-19 is spread more readily by airborne transmissions than contact with hard surfaces, infection control practices ramped up in the following ways:

Dental practices began screening patients for COVID-19 exposure and/or symptoms prior to their arrival at the office. Patients who disclosed exposures or symptoms were told to reschedule. These practices continue today in most dental offices.

In addition, dental practices started to require team members to self-screen for COVID-19 exposures and/or symptoms and to stay home if there are any. Some offices also began to inquire as to the vaccination status of their employees, which, although it is not a Health Insurance Portability and Accountability Act violation, it is a sensitive topic for some.

Dental practices began posting information about hand hygiene and cough etiquette in waiting rooms. Moreover, patients were told to call upon their arrival and stay outside offices until it was time for their appointments, which begs the question about the effectiveness of hygiene alerts posted in waiting rooms.

It became more common for dental team members to remove instruments from their packaging in front of patients rather than before their arrival. Not only does this limit exposure of these instruments to aerosols in the office but it also assures patients, who are understandably nervous about possible exposures to germs, that such instruments have been sterilized before their use.

 N95 respirators and face shields became the norm rather than the exception, particularly for aerosol-generating procedures. With the use of N95 respirators, most practices also began adhering with requirements by the Occupational Safety and Health Administration (OSHA) to fit test their respirators, at least annually, as well as develop and train team members on their respiratory protection programs.

Infection control classes became coveted, rather than dreaded, and focused more heavily on use and disposal of PPE, how to protect yourself and the patient during the appointment, and how to effectively disinfect the operatory after the patient leaves.

Given that COVID-19 is likely to persist in some capacity rather than go away completely, and there are other illnesses from which we should protect ourselves and our patients, we would expect and hope that many of the infection control practices emphasized during the pandemic will continue, including the following:

As we’ve learned more about the symptoms of COVID-19 (ie, high temperatures don’t necessarily indicate a COVID-19 infection, and some patients who have COVID-19 may have few symptoms, if any), questions on screening forms have changed. A focus on exposures rather than symptoms may be more useful.

 It is important for practices to train their team members on screening and communication policies. Otherwise, a team member who is sick may infect others, and an office may have no choice but to prohibit exposed team members from coming to work, informing patients of a possible exposure, and/or closing the office for a period of time—all of which can be detrimental to a practice.

With more people being vaccinated and the anticipated development of COVID-19 antiviral pills, it is more reasonable to envision a scenario where patients can come back into waiting rooms. Still, a dramatic increase in COVID-19 cases in the region or a single case in the office may require waiting rooms to remain sparsely populated.

It is in dental practices’ interests to properly set up and maintain operatories. Not only are patients’ worries about going or returning to the dentist heightened, but a shoddy presentation in the operatory may invite a nervous patient—or even a disgruntled employee or former employee—to take pictures with a handheld device and email them to OSHA or the state dental board.

Use of N95 respirators, face coverings, and gowns is probably here to stay. Annual fit testing also will continue as long as N95 respirators are being used.

Dentists and their employees will want to continue to stay educated about infectious diseases and best practices in infection control, especially as things change from time to time.

When thinking about the COVID-19 pandemic and, in particular, its impact on dental practices, this quote by writer Archibald MacLeish might come to mind: “There is only 1 thing more painful than learning from experience, and that is not learning from experience.”

Those dental practices that came out of the COVID-19 pandemic with an appreciation of and renewed commitment to infection control best practices will maintain the trust of their patients and survive, whereas those that scoff at the costs of doing the right thing will not. It’s as plain and simple as that.

Lisa Kane, DMD, is the owner of Dental Office Compliance of New England LLC (DOC4NE). DOC4NE assists dental practices in complying with the myriad of regulations required by their state board, OSHA, and the CDC. She teaches infection control and OSHA training, creates personalized plans and protocols for dental practices, and helps them navigate the world of dental compliance.

Alsaegh A, Belova E, Vasil’ev Y, et al. COVID-19 in dental settings: novel risk assessment approach. 

. 2021;18(11):6093. doi:10.3390/ijerph18116093

Dentistry workers and employers. Occupational Safety and Health Administration. Accessed November 29, 2021. https://www.osha.gov/coronavirus/control-prevention/dentistry

Those dental practices that come out of the COVID-19 pandemic with an appreciation of and renewed commitment to infection control best practices will maintain the trust of their patients and survive, whereas those that scoff at the costs of doing the right thing will not.

Infection Control in Dentistry Before, During, and After COVID-19

The SARS-CoV-2 virus was concerning enough, but just when we thought we were getting a handle on it, the variants started to emerge. First the Delta variant appeared, then the Lambda variant. And by the end of 2021, the Omicron variant revealed itself. However, for all the permutations of the virus, there are standard precautions that help prevent the disease’s transmission. In fact, those standard precautions are in place to keep everyone safe.

Germs, viruses, and bacteria are all things that infection prevention endeavors to mitigate. In a dental environment, sterile reprocessing is how patients are protected from contaminants on instruments.

Dental instruments may not seem as invasive as the instruments used in medical surgeries, but they still pose the same dangers. “You’re working inside people’s mouths,” said Lisa Kane, DMD, dental consultant and owner of Dental Office Compliance of New England LLC in Dedham, Massachusetts. “You have access to their bloodstream. You want instruments and tools that are clean, and the only way to ensure cleanliness is to sterilize them.” (Kane is the author of another article on dentistry in this issue on page 32.)

“Dental procedures are invasive, meaning they often come in contact with blood,” said Shannon Mills, DDS, private health care consultant and chair of the American Dental Association Standards Committee for Dental Products Subcommittee on Dental Infection Control Products. “Dental instruments used for what we call restorative procedures—which would include crowns, fillings, and for orthodontics—are classified as semicritical.”

Those semicritical instruments touch but do not necessarily penetrate mucous membranes. However, if they do, they can come in contact with blood, potentially passing along blood-borne diseases, such as hepatitis B or human immunodeficiency virus.

Infection prevention consultant, Katherine Schrubbe, PhD, RDH, MEd, BS, said sterile instrument processing is a vital component of the dental practice. “If we don’t have sterile instruments to utilize for our patient care, then you’re certainly just not working,” Schrubbe said. “You might as well just close the doors because you can’t treat anybody. It’s the standard of care. Every patient has to be treated as if they have something infectious.”

The primary method for dental instrument sterilization is through steam. However, cold sterilization is a process by which sterilization is achieved through a chemical means.

“It’s usually glutaraldehyde and they would put [in] things that are plastic that they wanted to reuse,” Kane pointed out. “It’s a high-level disinfectant, but the problem is that once you take it out of there, you have to rinse off the chemical. Then once you rinse off the chemical, it’s not sterile anymore.”

Steam sterilization also provides a measure of protection for dental staff. Chemical sterilants are hazardous to inhale, and autoclaves remove that risk. Steam sterilization is the preferred method now, but that wasn’t always the case. “If you roll the clock back 40 years, most of these instruments were cold sterilized,” Mills said. “They were put in some kind of a chemical bath—not even necessarily glutaraldehyde. When I first started, we simply wiped our hand instruments with isopropyl alcohol and put them in a drawer on racks. We’ve come a long way since the 1970s.”

Even though cold sterilization is still occasionally used, Schrubbe said most dental practices should avoid it. “There’s no reason for a dental practice to have any cold sterile,” she said. “Cold sterile is usually glutaraldehyde and is very toxic to human beings.”

Infection control is critical in dentistry—as it is in any health care environment—and it’s something practices take very seriously. That being said, dental practices still make common missteps. For instance, before being put into an autoclave, instruments must be thoroughly washed. “Although ultrasonics can dislodge material, sadly, a lot of times their cleaning process may be incomplete because of people rushing through it,” Mills said. “They’re also manually rinsing the instruments in the sink to remove the soil.”

Both disinfection and sterilization are 2-step processes. “There are always 2 steps, no matter what piece of that you’re doing,” Schrubbe said. “There is always a cleaning step. If it’s a surface, it would be disinfection. If it’s instruments, it would be sterilization. For example, when we clean our environmental surfaces—high-touch areas—most people use a disinfectant wipe.”

It’s necessary to clean a surface or an instrument before sterilizing or disinfecting. Schrubbe likens it to detailing a car. “You can’t wax your car until you wash it,” she said. “It’s the same sort of thing.”

Kane notes that some of the inconvenient-to-reprocess equipment is often overlooked. “It’s very important to autoclave all your handpieces and all the motors for your handpieces,” she said. “That includes prophy handpieces, and that includes slow speeds. Anything that comes off that hose has to be autoclaved, and it has to be done in between every patient.”

Once instruments come out of the autoclave, they must remain in their pouches until ready for use. Too often, practices make the mistake of opening those pouches, unwittingly exposing sterile instruments to contaminants, as well as other mistakes, Kane said. “A lot of people autoclave instruments, then take them out of the bag to store them somewhere. That’s not clean or sterilized anymore. It only maintains its sterility while it’s in the bag,” she said. “You can’t overfill the autoclave. You have to fill it according to whatever the manufacturer says. Different autoclaves have different requirements.”

For instance, sterility can’t be achieved if items touch the sides of the autoclave, hinged items must be in the open position, and the instrument bags must be left in the autoclave until they are dry, Kane explained.

How instruments are handled on the way to be reprocessed is also regulated, but in this case, it is out of concern for worker safety. “A lot of practices and team members don’t seem to be aware of this, but you must transport contaminated instruments a safe way from the operatory to your sterilization area. Occupational Safety and Health Administration [OSHA] mandates some guidance for that,”

 Schrubbe said. “And OSHA says if you’re going to transport your contaminated instruments from your operatory to a central sterilization area, you should have them contained. Basically, you should be transporting them in a container that is leak proof. It should have solid sides and bottom, and it should be labeled with a biohazard symbol.”

It is a common problem, as team members may not realize the reasoning behind having such a container. However, it is a means to avoid sharps injuries in the event somebody runs into a cart of loose, dirty instruments.

Team members must also wear the appropriate personal protective equipment (PPE) when handling dirty instruments. “When it comes to PPE, team members need to be wearing heavy-duty utility gloves anytime they do instrument processing where they’re handling contaminated sharps,” Schrubbe said. “Everybody says, ‘I don’t like to wear them.’ ‘They’re clumsy.’ ‘I’m going to have [more injuries] if I wear those, so I don’t.’ But we must remember our exam gloves are not chemical-resistant, and they’re not stick-resistant enough to protect us from a sharps injury when we’re handling all these instruments in the sterile processing area.”

Robert Elsenpeter is a freelance writer who lives in Blaine, Minnesota, and has been writing about dentistry and infection prevention since 2013. He is also the author of 18 technology books, including the award-winning 

Green IT: Reduce Your Information System’s Environmental Impact While Adding to the Bottom Line.

Dental instruments may not seem as invasive as the instruments used in medical surgeries, but they still pose the same dangers.

Brushing Up on Sterile Processing in Dentistry

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

Routine cleaning methods used to reprocess medical instruments could expose health care professionals to dangerous pathogens due to the splashing in sinks and other areas that it involves. It also matters what kind of personal protective equipment (PPE) the individuals are wearing. Those are 2 of the findings of a study published in December’s 

“This hypothesis-generating pilot project found that routine reprocessing activities generated substantial splashing, and currently recommended personal protective equipment did not adequately protect sterile processing personnel from exposure,” wrote the investigators, 1 of whom works at St Luke’s Hospital in Cedar Rapids, Iowa, and 3 others who work at the medical research firm Ofstead & Associates in St Paul, Minnesota.

Investigators gathered data by covering environmental surfaces and PPE with moisture detection paper. They then studied the droplet dispersal after health care workers performed routine reprocessing tasks.

“Visible droplets were generated during every reprocessing activity except running the sonication sink,” the authors wrote. “Droplets traveled at least 3 feet when filling a sink, brushing a ureteroscope, and using a power sprayer to rinse a basin. Some activities dispersed droplets up to 5 feet from the sink. [PPE] was splashed during most activities and did not prevent skin exposure even when properly donned and doffed.”

The authors noted that there is a lack of evidence about how traditional cleaning methods may contribute to contamination.

“[Personal protective equipment] was splashed during most activities and did not prevent skin exposure even when properly donned and doffed,” the study states.

Infection Control Today, January/February 2022, (Vol. 26, No. 1)

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Infection Control in Dentistry Before, During, and After COVID-19

Brushing Up on Sterile Processing in Dentistry

Changes COVID-19 Brought to Long-Term Care Facilities

Some Cleaning Methods May Contaminate Health Care Workers and PPE

Going Deep: Cleaning Potential of Electrostatic Sprayers

Omicron More Likely Than Delta to Cause COVID-19 Reinfection

Immune Changes in Mothers, Infants Linked to COVID-19 Infection

COVID-19 Spread: Droplets or Particles? It’s Not an Either/Or

COVID-19 Vaccine Uptake Among Health Care Workers Hits Wall