Championing infection control

Amid the many advances in technology, a significant focus on person-centered care and myriad research and tools available to long-term care providers, infections still seem to be among the most elusive to control and prevent. Indeed, healthcare-acquired infections (HAIs) such as pneumonia, ventilator-associated infections, diarrheal diseases, antibiotic-resistant staph infections and urinary tract infections (UTIs) are particularly challenging for nursing homes and even assisted living communities to manage.

Between 1 and 3 million infections occur every year in nursing homes and assisted living facilities. Nearly 400,000 long-term care residents will die annually as a result of HAIs, according to a 2017 Agency for Healthcare Research and Quality (AHRQ) report.

Research released in 2017 by the Centers for Disease Control and Prevention (CDC) found many nursing homes lack qualified personnel and other resources necessary to implement adequate programs to prevent HAIs. According to the researchers, “many infection control officers had little to no formal training and lacked foundational skills for proper infection prevention.”

Multiple government agencies have offered free resources about infection control and prevention in long-term care settings for years. The AHRQ, the National Nursing Home Quality Improvement Campaign and the CDC websites all have free assessment tools, training modules and fact sheets that cover antibiotic stewardship programs; improvement of antibiotic use; environmental cleaning and disinfecting; and prevention and management of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), norovirus, influenza and other pathogens.

So why do long-term care providers still struggle? As is the case with many a stubborn issue in many heathcare settings, the answer is not straightforward and it is not simple, especially when it comes to nursing homes.

Ruled by the new regs

The Centers for Medicare & Medicaid Services (CMS) issued new requirements for nursing homes in 2016 as part of its final “mega rule” on requirements of participation for long-term care facilities. The requirements, which have been met with an “it’s about time” expression of approval by many in the field, compel nursing homes to have a formal infection prevention and control program, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use, among other things. Larger facilities also must have an infection prevention and control officer on staff.

“It’s a very good step forward,” says James Marx, PhD, RN, CIC, FPIC, infection preventionist (IP) consultant. “I think the mega rule is addressing what’s been needed for such a long time and that is a dedicated infection preventionist in every facility.”

Although facilities have sometimes been reactionary when it comes to regulations, most of them want to be in compliance, Marx notes. “But because of all of the regulations already in place, they don’t have the resources, time and staff needed to do important things like infection prevention in a way that will be meaningful to both the residents and the staff.”

Clinical leadership makes a difference

Meaningful efforts to address the issue, Marx adds, include having someone in the facility who leads and champions the cause and is knowledgeable on the topic. “To me, that’s the thing that’s been needed for a long time,” he says.

Marx, a 2016 Fellow of the Association of Professionals in Infection Control and Epidemiology (APIC), notes the association has a multitude of resources for infection control and prevention, including an IP competency model and courses on the Education for the Prevention of Infection (EPI) certificate for long-term care professionals.

Although the requirement for training is not specific in the CMS regulation, “we think we are giving them a product they need in order to be successful in their program,” Marx says.

One of the more difficult challenges long-term care providers face is how much time should be dedicated to infection prevention activities. Although the person handling the IP role typically has an additional job position within the facility, Marx feels the IP program will be most effective when it’s led by an assistant director of nursing, an MDS coordinator or a wound care specialist—someone with clinical leadership experience. “In my opinion, it’s best to have the role combined with someone who has a clinical focus and a better idea of what’s going on with the residents on a day-to-day basis,” he says.

Communicate with CNAs

Since the majority of direct caregivers in long-term care are certified nursing assistants (CNAs), they play a significant role in infection control practices. Lisa Sweet, director of clinical affairs for the National Association of Health Care Assistants (NAHCA), recognizes that while the new requirements will cost some money to implement, the benefits will far outweigh the expense. “Having an infection preventionist on staff is very important,” she says. “Having a person with expertise who can do education and quality assurance, and monitor infection control and infection rates is key.”

Training is a crucial aspect of ensuring that CNAs are informed and ready to follow proper infection control practices, Sweet notes. “Sometimes, new CNAs are not trained like they should be due to short staffing and other factors, which can result in some staff doing it wrong from the start.”

MDROs on the rise

In February, the World Health Organization released its first list of “priority pathogens” and their resistances. Of greatest concern are gram-negative bacteria that are resistant to more than one medication and have learned how to pass along their resistance traits genetically.

Priority 1: CRITICAL

  • Acinetobacter baumannii, carbapenem-resistant
  • Pseudomonas aeruginosa, carbapenem-resistant
  • Enterobacteriaceae, carbapenem-resistant, ESBL-producing

Priority 2: HIGH

  • Enterococcus faecium, vancomycin-resistant
  • Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant
  • Helicobacter pylori, clarithromycin-resistant
  • Campylobacter spp., fluoroquinolone-resistant
  • Salmonellae, fluoroquinolone-resistant
  • Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant

Priority 3: Medium

  • Streptococcus pneumoniae, penicillin-non-susceptible
  • Haemophilus influenzae, ampicillin-resistant
  • Shigella spp., fluoroquinolone-resistant

Source: WHO (

Sweet also asserts that communication is an important component of effective infection control, especially when it comes to CNAs. “When you have a new shift coming on, it’s important for them to know what’s happening with residents. So many companies right now are trying to save money and some have eliminated shift overlaps,” she says. “What’s nice about overlaps—even if it’s 15 to 30 minutes—is that it enables CNAs to make rounds with the new shift so they can be brought up to date on residents’ conditions.”

Unique issues in memory care and assisted living

Although assisted living facilities are regulated at the state level, they too have unique issues when it comes to preventing and managing infections. Allissa Randazzo, BSN, RN, director of nursing for Aspen House Memory Care Assisted Living in Loveland, Colorado, says she trains her staff in infection control before they are ever on the floor with residents.

Although there are fewer issues with infections at her community, Randazzo says it is still a very important part of the quality assurance process. “Dementia brings its own unique challenges, and we have a number of residents who are in the late stages of the disease,” she says. “It’s sometimes difficult to control what residents touch and how they interact with each other.”

Although Aspen House has had only one case of C. diff., which was diffused successfully, Randazzo expects that the reality of rising acuity in assisted living will trigger more regulations for the states. In fact, Colorado enacted new infection control regulations in 2017 for assisted living facilities. “We have to have a quality management program, and infection control must be part of that. They are pretty broad, but it must be adequate for your population.”

More than 54 percent of state regulations specify requirements for some form of initial infection control training for all staff, according to a 2015 study published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA).

Staff training secrets

Marx, who has been training long-term care staff for more than 25 years, finds that role-playing is an effective way to get staff to understand the importance of things like changing gloves, donning gowns and washing hands. “I try to recreate real-life scenarios so they can be ready when it really happens,” he says.

Another critical component of the training and education is creating a culture support around staff as opposed to having a punitive environment. “This comes from the leadership in the facility,” he says. “Leadership, dedication and commitment from the medical director, the administrator and the DON are all important in ensuring proper management and prevention of infections at all levels.”

Topics: Articles , Clinical , Infection control , Regulatory Compliance