Staff shortages linked to infection citations in LTC

Taking a closer look at LTC mortality estimates

Fifteen percent of U.S. nursing homes receive deficiency citations for infection control per year, with many of those breaches tied to staffing issues, long term care researchers report.1

Conducted by a team of researchers at the University of Pittsburgh's (Pitt) Graduate School of Public Health, the study analyzed deficiency citation data collected for the purpose of Medicare/Medicaid certification between 2000 and 2007, representing approximately 16,000 nursing homes per year and a panel of roughly 100,000 observations. The records analyzed represent 96% of all U.S. nursing home facilities. The Centers for Medicare and Medicaid Services (CMS) requires that nursing homes be certified before receiving reimbursement for Medicare and/or Medicaid residents. As part of this certification process, facilities that do not meet certain standards are issued deficiency citations. This study examined the deficiency citation for infection control requirements known as the F-Tag 441.

The team discovered a strong correlation between low staffing levels and the receipt of an infection control deficiency citation. "Our analysis may provide some clues as to the reason for the persistent infection control problems in nursing homes," the authors found. "Most significantly, the issue of staffing is very prominent in our findings; that is, for all three caregivers examined (i.e., nurse aides, LPNs and RNs) low staffing levels are associated with F-Tag 441 citations. With low staffing levels, these caregivers are likely hurried and may skimp on infection control measures, such as hand hygiene."

In particular, a shortage of RNs was predictive of subsequent infection control citations, says lead author Nicholas Castle, MHA, PhD, a professor of health policy and analysis at Pitt. "It may be that the RNs provide more direction and more attuned to issues like hand washing," he tells Hospital Infection Control & Prevention. "So possibly the more RNs you have the better the infection control practices."

Low staffing levels are endemic throughout the nursing home industry, and thus promoting infection control measures may be challenging, Castle and colleagues concluded: "Our data show that receiving an F-Tag 411 deficiency citation for infection control is associated with poor quality of care in general (i.e., quality of care deficiency citations) and with the worst lapses in quality of care (i.e., level J, K, and L deficiency citations). This may be particularly significant for elder care. However, further progress in this area also may be spurred by recent changes in the F-Tag 441 deficiency citation by the CMS. In July 2009 and then again in September 2009, the CMS revised F-Tag 441 to encompass infection control and hand hygiene requirements."

Though those changes imply CMS now requires facilities to have a more formal infection control program, marked concern remains at the national level. Leading public officials are placing a high priority on improving infection control in long term care, in part because residents and patients in both non-acute settings and hospitals are moving multidrug resistant organisms across the whole healthcare continuum.

"One of the things they comment on in this study is the role of facility staffing, and I would also consider whether the stability of your staff — turnover rates — has influence on the knowledge and practice of infection prevention," says Nimalie Stone, MD, MS, a medical epidemiologist specializing in long term care at the Centers for Disease Control and Prevention. "One of their conclusions that we totally agree with is increasing education and training resources specifically directed for nursing home providers. That is a very important goal."

What is the real death toll in LTC?

In reviewing the literature, the study also cites a staggering mortality figure that appears recurrently in the long term research. The authors note that "between 1.6 and 3.8 million infections occur each year in these nursing homes, with almost 388,000 deaths attributed to these infections."2 The ballpark figure of "nearly 400,000 deaths annually" is also occasionally cited, raising the question of whether the mortality of infections in long term care is really four-fold that of the 100,000 patients who die annually of HAIs in hospitals. Or unbelieveably enough, could it actually be higher?

The truth is that the numbers reflect extrapolated mortality estimates from data that are now around a decade old. They have been preserved in the literature like amber because there is no national surveillance system for long term care infections — let alone their morbidity and mortality.

One of the studies frequently cited for the death toll was published in 2000, but Stone says even that work drew on 12 fairly small studies that date back to the 1980s and 1990s.3

"I would say we don't have a current estimate of the number of infections and outcomes [in long term care], but we know it is a very vulnerable group of people," she says. "They have a lot of reasons to have greater risks for infections and worse outcomes, and some of that is driven by the natural waning of the immune system that happens with age. As we age we tend to acquire additional medical conditions like diabetes, heart disease, lung disease, stroke— all of which contribute to our increased risk of infection or impair recovery from an event."

As infection prevention in long term care becomes a national priority and the CDC increases surveillance by expanding its existing hospital sentinel system, the toll of infections in long term care may come into better focus. The longstanding perception in hospitals that infections were an inevitable consequence of increasingly invasive care has been shattered by dramatic "zero infections" success stories in recent years. However, the old dogma may still apply in long term care, where as many people may die with infections as do because of them. In the short term, the issue is not likely to become any clearer as the walls between acute and long term care continue to come down.

"Estimates suggest that there is almost twice the number of cases of C. diff in nursing homes compared to acute care hospitals, but they are linked because many of those people have come from one sector to the other," Stone says. "It may just be because you are not in the hospital long enough anymore you manifest that complication somewhere else. I think that infections that are happening in nursing homes are also contributing to rehospitalizations and that's another healthcare initiative that both acute care and long term care will be aligned around. [We are trying to] understand those rehospitalizations and put in practices that can reduce those rates."

It remains an open question how many HAIs in long term care can be prevented, and correspondingly, how much that staggering death estimate could be reduced. Given the frequently cited lack of resources in long term care, one would think the increasing national emphasis could yield some dramatic results in nursing homes. On the other hand, the old mortality estimates were certainly based on resident populations with less acuity than those in long term care today. By that logic, the death toll may even be higher than the literature estimates.

Deborah Patterson Burdsall, MSN, RN-BC, CIC, corporate infection preventionist for Lutheran Life Communities, Arlington Heights, IL. has worked in hospitals and nursing homes over a career that spans decades. She recalls when most nursing home residents didn't even go to the hospital unless, for example, they fell down and broke a bone. By the same token, fewer of them came into long term care with vents, lines and other invasive devices.

"The acuity has changed drastically — I would say specifically in the last five years or so," she says. "They are as acute now as [patients] when I worked in a hospital."


  1. Castle NG, Wagner LM, Ferguson-Rome J, et al. Nursing home deficiency citations for infection control. Am J Infect Control 2011;39:263-9
  2. Richards C. Infections in residents of long term care facilities: an agenda for research report of an expert panel. J Am Geriatr Soc 2002;20:570-576.
  3. Strausbaugh LJ, Joseph CL. The burden of infection in long term care. Infect Control Hosp Epidemiol 2000; 21:674-679