Nursing home staff members, like everyone in the United States and across the globe, want to go back to “normal.” However, directors of nursing services (DNSs) need to ensure that infection prevention and control remains a priority both in the short term as COVID-19 vaccinations occur and in the long-term as the public health emergency eventually ends. Steps that DNSs can take to further these objectives include the following:

 In the near term

All providers are excited and grateful that COVID-19 vaccines are being rolled out to residents and staff, says Linda Behan, RN, BSN, CWCN, CIC, senior director of infection prevention and control at Genesis HealthCare in Kennett Square, PA. “However, the vaccine isn’t the be-all and end-all. Taking the vaccine doesn’t mean that everything is automatically all better.”

 Nursing homes and Assisted Livings will have to remain vigilant and continue with the same infection prevention and control practices that they have had in place throughout the pandemic, says Behan. “Whether it’s surveillance, personal protective equipment (PPE) use, or testing protocols—all of that needs to continue for a while. The COVID-19 vaccine will not provide immediate protection, and we need to see how the prevalence goes down in each nursing home’s local community. So, there is still a ways to go.”

“At the present time, the vaccine is not a complete solution,” agrees Connie Steed, MSN, RN, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC) and director of infection prevention at Prisma Health in South Carolina. “We have to get up to at least 70 percent to 80 percent vaccination levels to develop herd immunity before the Centers for Disease Control and Prevention (CDC) will begin to consider ending its recommendations to practice universal masking and other specific infection prevention and control steps designed to reduce the transmission of COVID-19.” 

Obtaining those vaccination levels may take time—even among healthcare workers, says Steed. “In our organization, we do have a mandatory staff flu vaccine program that includes our nursing home. However, we are not mandating the COVID-19 vaccine because it’s still an investigational drug. Instead, we will work through staff questions and strongly encourage them to take it. Some are early adopters and have already taken it. Whether it is right or wrong, others may feel more comfortable sitting back for a month or so to see how everyone else does. You need to be prepared to support staff through that process.” 

Note: See the Long-Term Care Facility Toolkit: Preparing for COVID-19 Vaccination at Your Facility from the CDC.

Ensuring that staff maintain infection prevention and control practices throughout the vaccine rollout will be challenging, adds Steed. “There is a lot of personal protective equipment (PPE) fatigue throughout the healthcare industry. To deal with that fatigue, you should maintain an ongoing monitoring process to ensure front-line staff are complying,” she explains. “You also should monitor residents. If the residents are out of their room, they are expected to universally mask too if they can.”

If monitoring reveals staff compliance issues, it’s important to stop and listen to those staff members, suggests Steed. “Part of PPE fatigue is utter exhaustion from all of the restrictions. Some staff are also angry, which is understandable. Everyone just wants the pandemic to end.”

Staff emotions can’t be ignored, stresses Steed. “You have to embrace the problem and deal with it. For example, we have brought in our employee assistance program to help front-line staff, and they do group sessions and provide other resources. In addition, supervisors check in on staff every shift. When they see concerns, they alert upper leadership to help target emotional support for staff.”

Going forward

Infection prevention and control will be an ongoing expectation even after the COVID-19 pandemic ends, says Steed. “Nursing homes face multiple concerns, ranging from antibiotic-resistant organisms to influenza and pneumococcal pneumonia.”

Note: In the latest sign that the Centers for Medicare & Medicaid Services will continue to prioritize infection prevention and control, the agency recently proposed a new outcome measure called the Skilled Nursing Facility Healthcare-Associated Infections Requiring Hospitalization for the Skilled Nursing Facility Quality Reporting Program (SNF QRP).

To ensure long-term success of infection prevention and control programs, DNSs should consider the following steps:

* Stay a champion. “DNSs and administrative leadership should continue to champion and collaborate with the infection preventionist to ensure a sustained infection prevention and control program,” says Steed. “The COVID-19 pandemic has highlighted that long-term care has a lot of vulnerability specific to infection prevention and control. It is very clear now that having an infection preventionist—part-time or full-time, depending on the organization’s size and complexity—is more than a regulatory requirement. You need an infection preventionist to ensure that the infection prevention and control program stays intact and is routinely assessed. At a minimum, there needs to be an annual risk assessment to look at the key components of infection control. That won’t happen without leadership support.”

* Maintain an “it takes a village” approach. “The pandemic re-enforced the concept that infection prevention and control ‘takes a village’ and is not solely the responsibility of a facility’s infection preventionist,” says Behan. She offers three examples of how providers can employ this approach even after the public health emergency winds down:
 

• Use infection preventionist designees on off shifts. “At Genesis during the first wave of the pandemic, each center’s infection preventionist trained additional staff, primarily nurses, in infection control to serve as infection preventionist designees,” says Behan. “Their role is to be the eyes and ears of the infection preventionist on off shifts: 3 p.m. – 11 p.m., 11 p.m. – 7 a.m., and weekends. For example, they monitor infection control practices on those shifts, as well as provide any just-in-time training or coaching needed by staff.”

  While the current focus is COVID-19, residents remain at risk for many other infections, notes Behan. “Consequently, we plan to ensure the continuation of IP designees on off shifts,” she explains. “Their findings about infection control practices on each of those shifts should still be reported every day at the morning meetings and, importantly, at Quality Assurance and Performance Improvement (QAPI) meetings.”

• Use staff members from other departments to assist with documentation and processes. “For example, we have utilized receptionists to help with front-entrance screening at Genesis centers. Even when COVID-19 is no longer the prevalent infection, visitors who enter nursing homes at any point in time will still need to follow basic infection prevention and control measures: cleansing their hands with alcohol-based hand sanitizer, following respiratory hygiene/cough etiquette, etc.,” points out Behan. “So, it should be re-enforced with receptionists to continue to direct visitors to where the alcohol-based hand sanitizer is and to provide a handout of general guidelines they should follow while in the facility.”

  Similarly, Genesis trained non-clinical staff to assist with data entry, says Behan. “Utilizing all of the facility’s resources in this way can free up time for nursing staff to focus on infection prevention and control after the public health emergency ends.”

• Do virtual rounding 24/7. “At Genesis, we’ve had success doing 24/7 virtual rounds, including on weekends,” says Behan. “We walk around via either an iPad or laptop and do virtual rounds, often unannounced, so that we can see what is occurring in the building. We talk to staff, ask questions, and just see whether staff practices are following facility policies day and night. Depending on an organization’s structure, this type of rounding could be done by facility leadership or even regional or divisional partners.” 

* Ensure that the infection preventionist retains power and access to resources. “The pandemic has given many providers a greater understanding of the role of the infection preventionist and all of the different facets that encompass infection prevention and control,” says Behan. “To sustain that heightened awareness going forward, nursing homes have to maintain the ability of the infection preventionist to continue to apply their knowledge and their expertise to prevent infections and, obviously, to prevent any kind of an outbreak. This means that infection preventionists will still need management backing to lead infection prevention and control practices not only in the nursing department but across all departments.”

In addition, infection preventionists also must be able to use available resources, including education, says Behan. “For example, at Genesis, our infection preventionists complete a 22.5 hour continuing education unit (CEU) accredited course that we created on infection prevention and control training.”

However, to maintain the infection preventionist’s ability to apply their knowledge and skills, they also need to stay up-to-date with changes, adds Behan. “So we have a weekly mandatory meeting with our infection preventionists to review updated CDC guidance or other national standards to make sure that practices at our centers are always current. Whatever a facility’s organizational structure is, there needs to be some type of mechanism for ensuring that infection preventionists have the education and resources they need on an ongoing basis. It really does help both the facility and the residents in the long run.”

* Use infection prevention and control data to drive process improvement. “During the pandemic, the CDC has used data to revise its guidance. For example, data has driven the guidance about asymptomatic transmission and testing requirements,” notes Behan. “At a facility level, providers also need to be using data—both internal data and external data, such as National Health Safety Network (NHSN) or other CDC data.”

The goal isn’t to simply collect numbers, stresses Behan. “You want to look at: What are your numbers telling you? You should incorporate the data into your QAPI process so that you can do the necessary root-cause analysis and determine what process improvements you may need to make to improve care and outcomes. You want to constantly improve. You should never be completely satisfied with your infection prevention and control program.”

AADNS – Caralyn Davis, Staff Writer

Questions?

Contact:

Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services
c: 425-231-4804