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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.
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
In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.
“That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”
While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”
Instead, the goal should be to come up with strategies that make sense, balancing safety and resident needs, says Snow. “Keeping these residents in a small room is highly improbable, so you want to be ready to move forward with some element of safety. You will put residents at risk if you aren’t prepared for the reality that they will come out of their rooms.”
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease (2019-nCoV or COVID-19), is spreading rapidly in nursing homes across the country. On March 23, the Centers for Medicare & Medicaid Services (CMS) announced that 147 nursing homes across 27 states have at least one resident with COVID-19, according to data from the Centers for Disease Control and Prevention (CDC). The number of providers with internal spread is increasing as well. For example, on March 25, news reports indicated that at least 16 residents and four staff members tested positive for COVID-19 in a West Virginia nursing home. Nursing homes that do not yet have COVID-19 in their facility should be actively working to mitigate the risk to residents and staff. Implementing the following strategies can assist in this effort:
Constantly monitor key infection prevention practices
Infection prevention auditing should highlight two areas:
* Hand hygiene. “From a self-inoculation perspective, the hands are the key,” stresses Michael Bell, MD, deputy director of the Division of Healthcare Quality Promotion at the CDC. “If you were to touch a soiled surface, you could end up with infectious material on your hands. If you then touch your eyes, nose, or mouth without washing your hands first, then you could deliver the infectious materials to yourself. Hand hygiene either in the form of alcohol-based hand gel or soap and water is the key to breaking that transmission. Simply walking into a room that might have something on the surface is not associated with any recognized risk of transmission.”
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