Infection preventionists (IPs) are the heroes of the pandemic, dealing with a profound crisis without proper training and resources, said experts in infection prevention and epidemiology during a recent “5 Second Rule” podcast from the Association for Professionals in Infection Control and Epidemiology (APIC).

The podcast, “#10 Advanced in Years Should Not Be Advanced with Tears: Infection Prevention and Control in Long-Term Care,” took an in-depth look at long-term care facilities.1

They have been hit “very, very hard” during the pandemic, said podcast host Silvia Quevedo, CCC-SLP, CAE, director of practice guidance for APIC. She cited a 2016 Nursing Economic$ article that said the nursing home population is hovering somewhere around 1.5 million and is expected to grow to 5.3 million in 2030.

“Why are these numbers so important?” she asked. “A large percentage of our population lives in these long-term care/assisted living settings. They are for the most part elderly or individuals with a lot of medical conditions, and so they are prone, more than healthy folks, to get healthcare-associated infections.”

This reality has never been more apparent than during the COVID-19 pandemic. Long-term care homes and assisted living centers house only 0.62% of the U.S. population, but account for 8% of all COVID-19 cases, and about 41% of all deaths in the United States.2,3

Defining the Situation

Quevedo asked podcast guest Angela Vassallo, MPH, MS, CIC, FAPIC, to define the terms they would be discussing, such as long-term care, nursing home, and assisted living. “It’s my understanding that this issue of infection control goes back a while with this setting,” she said.

This world involves a lot of acronyms, said Vasallo, the co-founder of COVID SMART, an infection prevention online education program for the general public. She also is a member of the associate faculty at West Coast University in Los Angeles, earned the APIC fellow designation, and is the current chair of the APIC communications committee. Long-term care (LTC) is the general umbrella for everything, Vassallo said. Long-term acute care (LTAC) is a hospital type of environment, but long-term.

“Then we have nursing homes, or what we refer to often in healthcare as SNFs, skilled nursing facilities,” she said. There are different types of SNFs, such as vSNFs, which have a higher level of care with specific training of staff to manage ventilators. Then there are distinct part (DP) skilled nursing facilities. “Those are nursing homes that are basically part of a hospital,” Vassallo said. “They are either a separate wing with a separate license or across the street, but they usually tend to be associated and close to a hospital.”

Then there is home health, assisted living, a myriad of other things that happen outside of the regular nursing home, hospital, acute care type of environment, she said. “When we think of long-term care, we are mostly thinking of nursing homes, where people live. The staff provides basic healthcare to them, but they are residents. It’s different from being a patient at a hospital. It’s their home.”

“Why is COVID-19 hitting this population so dramatically?” Quevedo asked. “What are some of the challenges within these settings for infection prevention and control and/or the spread of any disease?”

“One of the guiding principles is that residents that are residing in these facilities are often elderly,” said Evelyn Cook, RN, CIC, associate director for the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE). “They have comorbidities or other diseases. It is rare that you would find a resident with just one medical illness and/or problem.” Cook is the principal lecturer of all SPICE infection control courses and leads applied research projects in infection control and epidemiology.

“Just by the nature of growing older we have some factors that lend themselves to compromising our immune system or making us less resistant to infections,” Cook continued. “Simple things, like a decreased ability to cough well, the fact that our skin thins as we age.” LTC staff always have provided a level of basic medical care, but with COVID-19, they are being expected to provide a level of care they have never faced or been prepared to handle, she said. They deal with the availability of resources, staffing resources, even educational resources, as it relates to emergencies such as the pandemic.

A Look at Resources

Quevedo expanded on the topic of resources. In 2016, the Centers for Medicare and Medicaid Services (CMS) issued a rule requiring these types of facilities to have a designated IP. “Even back in 2016, this was recognizing the need for a more ‘robust’ infection prevention program, not because of COVID, which didn’t even exist back then, but because of other healthcare-associated infections that we talk about on the ‘5 Second Rule.’” The CMS rule shows that there were concerns with these settings, she said. She asked Vassallo to share about how staffing in these facilities typically works and how that might contribute to the problems we are seeing today.

“Staffing is a key issue in nursing homes when it comes to the work of infection preventionists,” Vassallo said. “The final rule that CMS passed in 2016 was a good thing because it said that we need a designated infection preventionist.” What that really meant, however, was that someone took the title of IP, but maybe didn’t have enough resources and training.

IPs in nursing homes tend to have several other titles, such as quality or risk, she said. They might be employee health, and they also might care for patients. In an environment where staff is minimal and the person who does infection prevention is doing lots of other things, sometimes infection prevention becomes the lowest on the priority list. “[For example], I am the IP in the nursing home, and I am supposed to be monitoring hand hygiene. If I have coworkers who are sick and I’m employee health, now I have to work with them on whether they should be at work. How long can they be out? If someone calls in sick, I may also have to start caring for patients.”

This is why they have had to go back to the basics during COVID-19 for infection prevention in nursing homes, Vassallo said. “Basic things like hand hygiene, environmental cleaning and disinfection, how to use personal protective equipment, and how to follow transmission-based isolation precautions, even just Standard Precautions, all seem suddenly more complicated because the people who do the work do not have the time to focus on these basic things. They are juggling lots of hats, and that has contributed to what is happening.”

To summarize, Quevedo said, even though the rule came about, the people serving as the IPs or in that role in these settings may not have always had the necessary training or capacity to even address the challenges.

“We have to recognize that these facilities are actually the residents’ homes,” Cook said. “They have had the opportunity to have their families visit as often as they liked. They bring their belongings from home. They establish their rooms as it would be our rooms in our home.”

Not only that, but the entire environment in these facilities used to focus on joint activities, joint dining, joint socializing, and therapy where there was joint socialization, she said. “Now, unfortunately, all of that has been put on pause. We have visitor restrictions; residents are requested to remain in their rooms. There are no more joint activities with friends they have made in the facility.”

Significant staff turnover is important to recognize, too, Cook said. “With a revolving door like that, it is difficult to maintain continuity and train staff because you are constantly re-educating and constantly orienting individuals. It has certainly been a challenge for them.”

Caught Unprepared

Quevedo asked about the challenges surrounding the use and disinfecting of personal protective equipment (PPE). Typically, before COVID, LTC facilities were using PPE for things such multidrug-resistant organisms like methicillin-resistant Staphylococcus aureus, Cook said. “Even with that, it was a modified version of what we do if the person is in the hospital. They had no system set up to really deal with airborne or respiratory pathogens.” Up until COVID-19, the biggest concern was tuberculosis (TB), and LTC facilities did not have to have a fit testing program (for an N95 respirator) or need to have one unless they were designated as a facility to care for TB patients.

In the COVID-19 environment, the other facilities now are being expected to do fit testing, Cook said. “You have to be trained in that process. It doesn’t just happen. You have to have the supplies available. And then you have to have the N95 masks.” Since this happened during the crisis, a lot of those resources are very difficult to get right now.

“It sounds like we had a perfect storm in these settings,” Quevedo said. “Then we have a pandemic that hits, and that’s why we see these crazy numbers among this population.” There are certified nursing assistants and other staff in nursing homes who may not be paid adequately and are forced to work in multiple facilities, she continued. “We know there is transmission that way. What can infection preventionists do? How can we fix this?”

A Silver Lining

“A lot of this seems dismal [during COVID-19], but there are some bright spots,” Vassallo said. “One is that we are seeing an increased collaboration across the continuum of care. For me, that means nursing home staff, hospital staff, surgery centers, clinics, and health department folks are talking to each other a lot more.

“In healthcare, we often work in silos, thinking about our building,” she said. “’I work for this hospital. This is what I am doing.’ What I have seen is this great sense of collaboration where people working in different healthcare environments in a community are communicating more. That’s a positive for us in the long run.”

Cook agreed. APIC is playing a primary role in encouraging that collaboration, both at the national and state levels, she said. “As professionals, it’s our responsibility to foster that collaboration and involve not just long-term care but other settings [such as outpatient]. As [Vassallo] mentions, these are all of our patients/residents people we are providing care for, regardless of what term we use to describe them.”

Vassallo said she knows that most IPs who are active members of APIC work in hospitals or as consultants in different settings. She encouraged her colleagues to get to know IPs who work in the nursing homes near their facilities. “It’s as simple as calling,” she said. “This is what I did when I was in Santa Monica at Saint John’s Health Center. I would look at the name of the [nursing home] and just call them. I would say, ‘Hi, I’m Angela,’ and introduce myself. I built some great relationships that way. I’m hoping we can see more of that.”

“It would make a big difference in preventing events like this from happening again,” Cook said.

Heroes of COVID-19

Quevedo closed the podcast by asking a final question: “What is bugging you about all of this?”

“I think what is bugging me the most is that long-term care facilities [and other facilities as well] are being expected to do things that they were never really expected to do before,” Cook said. “Some of those things the facilities were never designed to accomplish. It’s very difficult for them to maneuver through an outbreak such as this when they have never really been given the direction to do so.

“Long-term care facility staff are doing a phenomenal job,” she continued. “They are doing creative things with their residents: drive-bys, birthday celebrations, making bunny masks at Easter. They are just doing so many fabulous things, and I think we have to do everything we can to support them.”

“That is such a humane way to look at it,” Vassallo said. “I have such respect for nursing home staff, in particular infection preventionists who work in nursing homes. This is not easy work. People go into this because they believe in it. I would like to see infection preventionists within hospitals and APIC really support them, embrace them, and lift them up, because this time around, they are our heroes. They keep going to work every day, which I think is phenomenal. It’s humbling. I would like us to make them the spotlight of the work that’s happening in APIC this year.”

REFERENCES

  1. Association for Professionals in Infection Control and Epidemiology. #10 Advanced in years should not be advanced with tears: Infection Prevention and Control in Long Term Care. 5 Second Rule. July 14, 2020. 5secondruleshow.org/episode/10-advanced-in-years-not-advanced-in-tears/
  2. Roy A. The most important coronavirus statistic: 42% of U.S. deaths are from 0.6% of the population. Forbes. May 26, 2020. www.forbes.com/sites/theapothecary/2020/05/26/nursing-homes-assisted-living-facilities-0-6-of-the-u-s-population-43-of-u-s-covid-19-deaths/
  3. The New York Times. More than 40% of U.S. coronavirus deaths are linked to nursing homes. Updated Aug. 13, 2020. www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html