CMS can do better on infection prevention and control
Of the more than four million people in U.S. nursing homes, skilled nursing facilities, and assisted living facilities, the Centers for Disease Control and Prevention estimates that 380,000 die because of healthcare-associated infections annually. In an effort to reduce that alarming number, the Centers for Medicare & Medicaid Services included changes in infection prevention and control in nursing homes and skilled nursing facilities as part of its larger proposed “mega rule” to improve overall quality and safety requirements. This represents a significant step because much has changed in the infection-control landscape since CMS last updated its guidance 23 years ago.
In addition to infections harming residents, nursing facility staff is often occupationally exposed to infectious diseases. The most common routes of infectious disease transmission in nursing homes and skilled nursing facilities are contact and droplet. Contact transmission can be sub-divided into direct and indirect contact. Direct contact transmission involves the transfer of infectious agents to a susceptible individual through physical contact with an infected individual. Indirect contact transmission occurs when infectious agents are transferred to a susceptible individual when the individual makes physical contact with contaminated items and surfaces.
One of the more serious contact infections that the CDC has identified as an urgent threat is Clostridium difficile (C. difficile), a deadly infection that causes inflammation of the colon. In February 2015, the CDC released a study that revealed more than 100,000 nursing home residents develop C. difficile infections each year.
Droplets containing infectious agents are generated when an infected person coughs, sneezes, or talks, or during certain medical procedures, such as suctioning or endotracheal intubation. Transmission occurs when droplets generated in this way come into direct contact with the mucosal surfaces of the eyes, nose, or mouth of a susceptible individual. One of the most common examples of droplet transmissible infections is the influenza virus.
Unfortunately, the proposed CMS rule on infections is currently too broad to make much of an impact. Without mandates for specific rules on antibiotic stewardship, infection surveillance, prevention, and control, many otherwise preventable infection-related illnesses and deaths will continue unabated.
Antibiotics rank as among the most frequently prescribed medications in nursing homes. Up to 70% of residents receive one or more courses of systemic antibiotics in a given year. Yet studies show that anywhere from 40% to 75% of these antibiotics may be unnecessary or inappropriate. Harms from antibiotic overuse significantly threaten the health of nursing home residents, including increased risk of serious diarrheal infections, adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms—an increasingly alarming public health issue. Some of these health threats also extend to staff.
For instance, among the most dangerous risk factors for patients who take antibiotics is development of C. difficile. Unnecessary antibiotic use and poor infection control may increase the risk of C. difficile spreading within and among facilities.
Yet, in its proposed rule, CMS gives no guidance about how facilities should perform antibiotic stewardship, which is a coordinated plan designed to optimize treatment of infections and promote appropriate use of antibiotics. CMS should consider mandating the CDC's evidence-based “Core Elements of Antibiotic Stewardship for Nursing Homes.” This program would also provide state surveyors with guidelines to help them monitor effectiveness.
Another concern about the proposed rule is the lack of instruction for staff on how to conduct infection surveillance. Infection surveillance can provide long-term care facilities with valuable information to monitor problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections. CDC research shows that when healthcare facilities, care teams, and individual practitioners recognize infection problems and implement specific steps for preventing them certain infection rates can decrease by more than 70%.
Currently, all CMS-certified nursing facilities use the Minimum Data Set for collecting information on infections that impact longer-stay residents. However, the U.S. Department of Health and Human Services — the umbrella agency that effectively serves as CMS' boss — makes the following point in its 2013 National Action Plan to Prevent Health Care-Associated Infections: “There are limitations to using MDS data as a universal data source to track HAI in nursing homes.”
The concern is that the assessments offer data for only a particular point in time, often only quarterly, and that the time between assessments may not capture important changes, including new infection events. Additionally, the MDS does not capture multiple infections, timing of infections, or any data on short-stay residents admitted from the hospital setting for rehabilitation. The goal of calculating infections should not be just to count, but to portray the full scope of infection patterns and to then identify areas in which to intervene.
For the last several years, hospitals and other acute care settings have used the CDC's National Health Safety Network surveillance system to keep track of infections. Currently, 32 states and Washington, D.C., are legally required to report HAI data from 17,000 participating hospitals and other acute care settings to the NHSN. Nursing homes and skilled nursing facilities should be required by CMS to adopt the NHSN system for their infection surveillance.
Finally, CMS should include a mandate that requires all nursing home and skilled nursing facility staff who work directly with residents to get an annual flu vaccine. According to a 2010 CDC survey, over a third of healthcare professionals working in long-term care facilities did not receive a seasonal influenza vaccination. Long-term care facility residents are particularly vulnerable to contracting influenza because of often compromised immune systems, as well as the fact that their healthcare setting often serves as their home. By extension, if a resident catches the flu, a staffer has an increased chance of catching it as well.
CMS has an opportunity to make a significant difference on this issue. However, until it does so, healthcare-associated infections will literally remain a life-and-death issue for our nation's long-term care residents and the staff who devote their careers to their care.
Susan Peschin, MHS, serves as President and CEO of the Alliance for Aging Research in Washington, D.C.