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The Centers for Disease Control and Prevention (CDC) has replaced the Interim Additional Guidance for Infection Prevention and Control for Patients With Suspected or Confirmed COVID-19 in Nursing Homes with a new set of core practices, as well as tiered recommendations to nursing homes in different phases of COVID-19 response. Note: The tiered recommendations are consistent with the Centers for Medicare & Medicaid Services’ (CMS) recently released recommendations for a phased-in approach for reopening nursing homes.
One of the new core practices focuses on ensuring the facility’s infection preventionist has enough hours to do the job:
Assign One or More Individuals With Training in Infection Control to Provide On-Site Management of the IPC Program.
This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the facility risk assessment.
CDC has created an online training courseonline training courseonline training class online training coursethat can be used to orient individuals to this role in nursing homes.
“We would really encourage facilities to assign and dedicate one individual with infection prevention and control training to be the onsite manager of their COVID-19 prevention and response activities full-time,” says Nimalie Stone, MD, medical epidemiologist for long-term care in the Division of Healthcare Quality Promotion at the CDC.
Editor’s note: This is the first article in a multipart series about advance care planning and how to operationalize an effective program in nursing homes.
The surveyor guidance under F578 (Request/Refuse/Discontinue Treatment; Formulate Advance Directives) in Appendix PP of the State Operations Manual defines and discusses advance care planning as follows:
“Advance care planning” is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. …
The ability of a dying person to control decisions about medical care and daily routines has been identified as one of the key elements of quality care at the end of life. The process of advance care planning is ongoing and affords the resident, family, and others on the resident’s interdisciplinary health care team an opportunity to reassess the resident’s goals and wishes as the resident’s medical condition changes. Advance care planning is an integral aspect of the facility’s comprehensive care planning process and assures re-evaluation of the resident’s desires on a routine basis and when there is a significant change in the resident’s condition. The process can help the resident, family and interdisciplinary team prepare for the time when a resident becomes unable to make decisions or is actively dying.
But what exactly does that mean? “The commonly used definition of advance care planning is that it is a process to support a person in understanding and ensuring their values, goals, and preferences regarding future medical care,” says Shigeko (Seiko) Izumi, PhD, RN, FPCN, associate professor in the School of Nursing at Oregon Health & Science University in Portland, OR; presenter of the April 22 webinar “COVID Conversations: Team Approach To Assisting Patients With Advance Care Planning” from the Coalition for Compassionate Care of California; and co-author of “A Model to Promote Clinicians' Understanding of the Continuum of Advance Care Planning” in the Journal of Palliative Medicine (2017; 20(3):220-22).
“It’s very important to know the resident’s values, goals, and preferences of future care and then to share that information with families and other healthcare providers so they understand what kinds of care the resident wants when that resident is unable to make their own decisions or cannot express their wishes,” she explains.
Personal protective equipment (PPE) is currently a topic of discussion on a global level. The COVID-19 pandemic has brought infection control procedures and the use of PPE under intense scrutiny, especially in long-term care. On a daily basis, we hear about the shortcomings of PPE supply and use, along with the lack of proper infection control in healthcare. Do not let the negative publicity paralyze you. As a leader, it is imperative to analyze what occurs in the facility and find ways to improve. By investigating competency and compliance, directors of nursing or other nurse leaders, such as infection preventionists, can improve PPE utilization in their facilities.
History of PPE
Since Leonardo DaVinci invented the first respirator to prevent contamination from chemical warfare in the 16th century, healthcare personnel (HCP) have been attempting to protect themselves from illness (Segal, 2016). As understanding of pathogens increased, PPE have evolved in response. PPE as we know it today originated in the 1970s when the Centers for Disease Control and Prevention (CDC) published the manual Isolation Techniques for Use in Hospitals. In the 1980s, PPE use intensified due to the human immunodeficiency virus (HIV) pathogen, which led to universal precautions being introduced in 1985 to prevent the transmission of infection. In addition to the gowns and gloves already being utilized, facemasks and eye shields were implemented to protect mucous membranes. In 1989, the Occupational Safety and Health Administration (OSHA) proposed a rule on occupational exposure to bloodborne pathogens. The rule on bloodborne pathogens was then finalized and published in 1991. The CDC issued an isolation guideline in 2007 which addressed PPE, including the donning and doffing procedures (Segal, 2016).
Transmission-Based Precautions and PPE
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
Almost 200 years ago, physicians discovered that deadly pathogens were transmitted from patient to patient via the hands of nurses and physicians, and that washing hands between appointments with patients would dramatically reduce the mortality rate (World Health Organization, 2009). While tremendous strides in hand hygiene compliance have been made since the 19th century, there is still room for improvement—as the Centers for Medicare & Medicaid Services (CMS) noted during its Call with Nursing Homes on May 13, 2020 (CMS, 2020). The CMS Northeast Division Director for Survey and Reinforcement named three areas of practice that surveyors have noted need improvement, and hand hygiene was at the top of the list.
Factors Affecting Compliance with Hand Hygiene
Properly washing hands and performing hand hygiene is an essential skill every healthcare worker (HCW) must possess. The AAPACN Hand Hygiene Competency Tool can assist nurse leaders documenting achievement of competence with this skill. However, competence does not necessarily translate into compliance.
A systematic review of the research studying hand hygiene of HCW in the hospital setting found several factors affect compliance (Erasmus, et. al, 2010). While the nursing home setting is unique and poses different challenges from the acute care setting, the findings from this study can enlighten the Infection Preventionist (IP) and other nurse leaders as to factors they may consider when working toward improving hand hygiene compliance in the nursing home. See the table below for some helpful factors to consider.
The Centers for Medicare and Medicaid Services (CMS) has tried to make it easier for dialysis providers to offer home dialysis to long-term care residents to reduce the risks of COVID-19 transmission. Note: For more information, see Quality, Safety, and Oversight (QSO) memo QSO-20-19-ESRD – REVISED, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Dialysis Facilities, as well as the Expanding Availability of Renal Dialysis Services to ESRD Patients section of COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.
However, home dialysis often isn’t a realistic option, says Mary Gruel, RN, CDN, education coordinator at Tri State Dialysis in Dubuque, IA, and program coordinator for the April 2020 Spring Clinical Meetings’ nursing track at the National Kidney Foundation. “During the pandemic is not the time to change modalities to home therapy,” she advises. “Most dialysis facilities don’t have the training and staffing capacity to make that transition for multiple residents or the extra machines that would be needed to provide that service in the facility.”
Consequently, many nursing homes will need to continue to send residents out for dialysis treatments for the duration of the pandemic. However, taking the following steps can help mitigate the risks:
Assess whether you should cohort dialysis residents
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