Even before COVID-19, infection prevention and control was a standard component of the long-term care survey process—and a frequent source of F-tag citations—because of residents’ significant vulnerability to infection. Note: For details, see the May 20 General Accountability Office report, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.
“However, the SARS-CoV-2 novel coronavirus, which is the virus that causes the disease that we call COVID-19, takes this need for excellence in infection prevention to an entirely different level that has never been seen before in U.S. nursing homes,” says Paul McGann, MD, the chief medical officer for quality improvement at the Centers for Medicare & Medicaid Services (CMS). McGann and others presented at the May 28 webinar, Establishing an Infection Prevention Program and Conducting Ongoing Infection Surveillance in the Nursing Home, from CMS and the Quality Improvement Organization (QIO) Program.
Best-practice strategies for establishing an infection prevention program and conducting ongoing surveillance include the following.
Step 1: Complete CDC infection preventionist training
Providers have responded differently in implementing the requirement for a designated infection preventionist, says Eli DeLille, MSN, RN, CIC, FAPIC, a quality improvement specialist and infection preventionist with the QIO, Health Services Advisory Group. Note: All three phases of the revised Medicare/Medicaid requirements of participation established in the 2016 Reform of Requirements for Long-term Care Facilities Final Rule are in effect as of November 28, 2019. These infection control regulations, including the requirement for a designated infection preventionist and the much newer COVID-19 reporting requirements, can be found at 42 Code of Federal Regulations (CFR) 483.80. The guidance to surveyors is available in Appendix PP of the State Operations Manual.
For example, one facility may have a full-time dedicated infection preventionist, which is now the standard recommended by the Centers for Disease Control and Prevention (CDC) for facilities with more than 100 residents or on-site ventilator or dialysis services.
Another facility may split those responsibilities among two or more staff members. For example, the director of staff development, the director of nursing services (DNS), and a licensed vocational/practical nurse could all have defined responsibilities as part of a team approach to the infection preventionist role. However, these providers should create “a hierarchy where one person has ultimate accountability for that role,” says DeLille.
Whatever model a provider uses, they can better ensure a consistent approach based on recommended practices by using the CDC’s Nursing Home Infection Preventionist Training course as an educational launch point, says DeLille. While full-time infection preventionists “should definitely take this,” it’s even more important for staff who share infection preventionist responsibilities “because you want to make sure that you have that foundational knowledge to make the best decisions for your residents and staff.”
The CDC course is self-paced and on demand, with some modules as short as 15 minutes, says DeLille. “It is meant for a working staff member to take when you have time, and based on your needs, you can prioritize certain trainings as they are available in different modules. There is also continuing education offered.”
Step 2: Use the QIO checklist to orient IPs and ensure training consistency
As beneficial as the CDC course is, it doesn’t “perfectly prepare” infection preventionists to orient themselves within that role at a facility level, says DeLille. Consequently, the QIO Program has created the Infection Preventionist Orientation Checklist.
This checklist standardizes the essential components of an infection prevention program, says DeLille. “In addition, it ensures consistency of training across multiple staff members in case you are not a facility that can dedicate a single person.”
The checklist is designed to allow facilities to keep one for every staff member who is operating in an infection prevention capacity to demonstrate these staff members have been “systematically educated,” says DeLille. “They could go through this as they have time and sign off the skills that they have developed in their new role.”
Step 3: Use the ICAR tool to assess gaps in infection prevention practices
The CDC offers an Infection Prevention and Control Assessment Tool for Long-term Care Facilities (aka an ICAR tool) “to evaluate a nursing home’s preparedness efforts around general infection prevention,” says DeLille. While the CDC also has created a COVID-specific ICAR, this tool is a “great general assessment” for conducting an overarching program evaluation, says DeLille. “I don’t think I have ever gone out and done an audit without having findings from that audit that I needed to action.” Note: CMS also offers survey COVID-specific and general infection prevention survey tools that may be helpful in assessing gaps.
The general CDC ICAR tool helps facilities review their policies and protocols. “It is going to set the expectation,” says DeLille. “Then you will go out and observe facility practices [to determine] if people are complying with what your policies and practices are.”
Step 4: Prioritize the findings
The next step is to “make long-term plans for where you want your infection prevention program to go,” says DeLille. “And risk assessment is the best way to approach that.”
While other organizations, including the CDC, have tools for prioritizing risk, the QIO Program has developed a simplified version, the Infection Prevention Post-Acute Risk Assessment Prioritization Worksheet, based on feedback from nursing home partners, says DeLille.
The worksheet allows providers to assign low, medium, or high risk scores in three key areas (i.e., the probability the risk will occur, the potential severity if the risk occurs, and how well-prepared the organization is for that risk) for staff issues (e.g., hand hygiene), environmental issues (e.g., lack of cleaning in patient care areas), and catastrophic events (e.g., internal outbreak). Comparing risk levels in this way helps providers focus infection prevention efforts and appropriately allocate finite resources and staff time, says DeLille.
It’s important to note that the tool is modifiable, says DeLille. “I am positive there is something within your facility that we have not addressed. So you need to make sure that you are aware of that risk; you are adding it to this risk assessment; and as a team, you are deciding whether or not you need to move in a direction where you need to put controls in place to prevent any sort of negative resident outcome.”
Step 5: Develop a customized action plan
The QIO Program has created a modifiable template, the Infection Prevention and Control Post-Acute Plan Prioritized Risks, Goals, Strategies, and Implementation, to help nursing homes create customized action plans. Providers should consider the best practices listed in the tool to be a summary of national strategies and high-level state strategies, advises DeLille. “You need to make sure that you modify this plan to fit the needs of your particular organization. Some facilities need to add much more than what we have listed.”
To implement the action plan, “you need to make sure that you are assigning accountability,” says DeLille. “The infection preventionist helps to own the plan, but they cannot own the process. Managers, staff and even providers [i.e., physicians] or owners should be involved.”
The implementation plan also should have a time frame, says DeLille. “There has to be an expectation that you will have these components implemented by a certain date.
In addition, the plan should include an auditing component to evaluate its effectiveness, says DeLille. “Your goal should be customized in a way that is measurable over time so you can show if you are meeting goals or if you are not meeting goals, and then you add additional strategies for any failures that you might identify with your plan.”
Finally, there should be a process to escalate concerns when warranted, says DeLille. “You need to feel comfortable taking a concern to your medical director, your director of nursing, or your facility administrator, and you have to know that it will be addressed.”
Facilities with a full-time infection preventionist will find it easier to implement an action plan, notes DeLille. Providers that don’t have that luxury should consider creating a subject matter expert as part of the infection preventionist team. The key is to divvy up responsibilities “in such a way that it makes you successful as a team and you don’t provide confusing information to your partners,” he adds.
Step 6: Solicit feedback
Action plans that are created in a silo and rolled out to staff often fail miserably, says DeLille. “You want to solicit feedback. Meet with key partners (e.g., the medical director, nursing staff, the consultant pharmacist, dietary staff, etc.) to ensure that you have met each one of their needs. They are the ones who will be helping you audit and advocate for the staff members that are really implementing this on a day-to-day basis.”
Step 7: Implement wisely
“You need to make sure that you are educating staff members regarding expectations of care,” says DeLille. “Once again, when you make decisions in a silo and don’t engage that frontline team member, you are almost defeating yourself before you have even begun.”
Staff also should be empowered to speak up if they identify concerns, he advises. “As an infection preventionist, there unfortunately is a tremendous amount of desk work that has to be done. You need to rely on team members to come to you.” An open-door policy only works if the infection preventionist’s relationship with staff is collaborative, not punitive, adds DeLille.
It’s important to engage staff members, physicians, and residents in infection prevention practices, adds DeLille. “Sometimes when infection preventionists recommend what is plainly not very popular, people look at it as additional steps. However, if you take the time to educate and inform, you make yourself available, and you live by the guidelines that you provide to others, it will make you more successful in this role.”
Finally, providers shouldn’t be afraid to change the action plan, says DeLille. “When you work diligently—sometimes for months—to put a process in place, it almost becomes like you internalize it and its failure is your failure. But sometimes something just won’t work. You have the best of intentions, and still it does not meet the needs of your residents or there is a change in regulatory requirement.”
Step 8: Conduct ongoing surveillance
Surveillance is “when you have really moved from a reactive state to a proactive state,” says DeLille. There are two types:
- Process surveillance. This identifies whether there is a disconnect between facility policies and procedures and actual staff practices, says DeLille. “An infection preventionist cannot do this alone. Your administrator needs to help, as does your director of nursing, your assistant director of nursing, and your frontline staff. Everyone needs to hold each other accountable to ensure that you are meeting the resident’s needs and you are doing so in a safe fashion.”
- Outcome surveillance. “This is when you collect data based on individual residents and then compare that to standardized definitions of infection,” says DeLille. For example, some providers use the McGeer Criteria, and some use the more limited National Healthcare Safety Network (NHSN) long-term care surveillance definitions. Note: The Loeb criteria are person-centered criteria for starting antibiotics, not surveillance definitions.
Surveillance should come from both concurrent and retrospective reviews, notes DeLille. However, concurrent reviews require a strong process, so providers may want to start with retrospective reviews and then work up to concurrent reviews. “But either way, you need to make sure you are using a standardized format and that you take that format to your team so that you are setting clear expectations. For example, if you are looking at isolation, what are your expectations around isolation? If you just start telling people that they are doing something wrong and you never spend time educating them to begin with, it sets you up for failure.”
Critical infection control reports that the infection preventionist should review to look for trends and patterns that could have a negative impact on residents include the following:
- Daily isolation report. “You often can create a flag within your system so it says what isolation the patient is in; why; and, if it can be discontinued, the date of. That’s a great way for you to meet the needs of your resident and communicate clearly to your staff why they are in isolation precautions,” says DeLille.
- Daily positive lab report. “Looking at that daily line list of positive cultures is a great way for you as an infection preventionist to know exactly what is happening within your house and if you have a problem,” says DeLille.
- Antibiotic use report. This report allows the infection preventionist to see any resident who is started on a new antibiotic, says DeLille. “If you have leadership support, you then can have some collaborative discussions with your medical providers about antibiotics that may be putting a resident at higher risk of a multidrug-resistant organism.”
Surveillance should be a continuous, daily process, says DeLille. “Typically, you are not looking at a tremendous amount of time. However, when you run across an infection, it does take more time. You need to set enough time apart to go in and truly assess what is happening the same way that you [optimally may take several hours] to check isolation compliance or hand hygiene compliance.”
Note: This webinar was the first in an eight-part weekly series to provide nursing homes with training for infection control processes that will run every Thursday through July 16. Future webinar topics include other core competencies, such as testing, surveillance, cohorting, screening of visitors, and the proper use and deployment of PPE. Find the May 28 on-demand video, presentation slides, and related tools here. Sign up to receive notices about upcoming webinars and other resources by e-mail here. In addition, each of the 12 QIOs will provide technical assistance on infection prevention and control programs. Find the QIO for each state here.
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