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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
Quickly identifying and communicating relevant changes of condition to clinicians (e.g., physicians, nurse practitioners, or physician assistants) has long been a challenge for many nursing homes. However, timely, efficient notifications are more critical than ever during the ongoing COVID-19 pandemic because directors of nursing services (DNSs) have to guard against potentially catastrophic COVID-19 spread in their buildings in addition to addressing each resident’s individual clinical concerns. The following steps can help DNSs ensure their teams stay on top of changes of condition:
Use a tool that structures the nurse-clinician conversation
Communication between nurses and clinicians can be difficult,” says Joseph Ouslander, MD, professor of geriatric medicine and senior advisor to the Dean for Geriatrics in the Schmidt College of Medicine at Florida Atlantic University in Boca Raton, FL; author of the editorial “Coronavirus Disease19 in Geriatrics and Long-Term Care: An Update” in the Journal of the American Geriatrics Society; and the primary creator of the free INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program. “Sometimes nurses don’t know the resident very well, and sometimes the physician is on call and doesn’t know the nurse, the facility, or the resident very well. There is also a struggle to determine what information is important to communicate to clinicians and what is not important. What are the pertinent negatives that should be communicated? What are the pertinent positives?”
To gather the necessary information, nurses should complete an assessment when staff identify a potential change of condition. In many facilities, this assessment is done using a tool that gathers information using the SBAR (Situation – Background – Assessment – Recommendation) format. The Agency for Healthcare Research and Quality (AHRQ) defines SBAR as follows:
Directors of nursing services (DNSs) and other managers can support and motivate staff in two critical ways: individually and organizationally. Taking the following steps can help staff deal with the anxiety of caring for residents in a pandemic:
Teach staff how to help each other—and themselves
Judy Davidson, DNP, RN, FCCM, FAAN, a nurse scientist at UC San Diego Health and co-chair of the Strength Through Resiliency Task Force at the American Nurses Association, offers the following two stress reduction techniques that DNSs can use themselves and teach staff as well:
* Tap Out and Take a Lap. “If you see someone at work whose anxiety level is rising, you figuratively tap them out and invite them to take a lap of the unit with you. A lap of the unit usually takes about one minute, and that is all it takes to do this stress reduction technique,” says Davidson. “While walking, you coach them through a little breathwork. If they are really panicked, just do four breaths in and four out. Doing that for five cycles will add up to a minute—which is all it takes to break the stress response that the person is under and ground them again so they can get back into the game.”
If the person isn’t totally panicked, “they may be able to tolerate a more complex breathing pattern, four-seven-eight: Breathe in for four, hold for seven, and breathe out for eight. Four to five repetitions of that will give you a minute that you have walked around the unit, and now both you and your colleague are feeling better,” says Davidson. “I recommend anyone to do that for helping out in-the-moment stress.”
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.”
Telehealth has existed for quite a while, and as its use has expanded in recent years, some healthcare groups have even provided the services to their entire network of facilities. These networks often paid for telehealth access out of their own pockets, as accessibility and financial assistance for Medicare beneficiaries has previously been very limited, with coverage only available to facilities in designated rural areas and only for patients who had a previously-established relationship with their doctor. However, on March 6, the $8.3 billion dollar Coronavirus Preparedness and Response Supplemental Appropriations Act was passed, which allowed the Department of Health and Human Services (HHS) “to temporarily waive certain Medicare restrictions and requirements regarding telehealth services during the coronavirus public health emergency.”
Then, on March 13, President Trump declared the COVID-19 outbreak a national emergency. And thus, we received the 1135 waiver, which expanded telehealth services:
Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
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