Long-term care remains in the dark about infection preventionist requirements

The need for infection preventionists has never been greater, but 13 months into the COVID-19 pandemic, long-term care providers still remain in the dark as to who will fit the federal government’s final criteria.

The nation’s nursing homes are awaiting final interpretive guidance from the Centers for Medicare & Medicaid Services, which will define who can be an IP, how much of their job they should commit to infection work and what qualifications or training they must have.

The position was mandated as part of a broad focus on infection prevention and control in the 2016 Rules of Participation. But just weeks before the IP provision was to go into effect in 2019, CMS leaders announced they wouldn’t push out guidance — and would limit enforcement — until the second quarter of 2020.

Then COVID-19 hit, and at a time when infection prevention remains mission critical, federal officials again put off issuing binding guidance.

Instead, providers have been left to fill the infection preventionist role in a vacuum. Some states already require the hiring of nursing home IPs, but their standards, too, are often open to interpretation leading to concerns about programmatic quality.

In Illinois, for instance, a 2011 rule requires each building to have an infection preventionist, but the scope of that job was never truly defined. While intended to give providers flexibility, that approach allowed preventative efforts to fall through the cracks, said consultant Deb Burdsall, Ph.D., RN-BC.

“The pandemic has made clear that a lot of people that were trying to fulfill that role — a lot of times with good-faith efforts — found it was an independent profession, not an ‘other duty as assigned,’” said Burdsall, a certified infection preventionist who spent 25 years in that position with Illinois-based Lutheran Life Communities. “It requires time, it requires training and education. It requires maintaining contact with the local health department and local organizations and with your colleagues. You can’t do this in a silo.”

What counts as training?

Nursing home IP standards during COVID-19 have been dictated by the Centers for Disease Control and Prevention, which called on facilities to have “one or more individuals with training in infection control to provide on-site management of the IPC program.” The CDC insisted the IP be full time in any facility with more than 100 residents, or if residents receive on-site ventilator or hemodialysis services.

But even that guidance leaves providers grappling with what counts as training. The CDC offers a nursing home infection preventionist course, and some states have also established their own training programs. 

The Association for Professionals in Infection Control and Epidemiology (APIC) strongly recommends more comprehensive training that prepares IPs to earn an endorsement from the Certification Board of Infection Control and Epidemiology.

Evelyn Cook, R.N., CIC, is associate director of the statewide program for infection control and epidemiology at University of North Carolina at Chapel Hill and serves on APIC’s Long Term Care task force.

She said certification and membership in a professional infection control organization are key ways for IPs to grow their knowledge and stay updated on emerging threats. But just 1,200 APIC members currently identify as working primarily in long-term care, representing less than 10% of U.S. nursing homes.

In a 2018 study seeking to establish baseline knowledge about nursing home IPs, Columbia University School of Nursing’s Patricia Stone, Ph.D., RN, found that just 39% had received “specialized training” and less than 3% of those held any IP certification.

A second study, published in 2020, found the percentage of nursing homes with IPs had increased from 3% to 7% between 2014 and 2018, a period when facilities strengthened antibiotic stewardship, outbreak control and urinary tract infection prevention. 

But in 2018, 44% of nursing homes still reported their IPs had no specific infection-control training.

One of the challenges is that the CBIC standard, APIC’s gold standard, tests on a significant amount of acute-care information — such as sterilization of surgical instruments — that nursing home IPs would never need. To that end, Cook said APIC is working to create a competency designation for IPs that work in long-term care settings. Expected to be available this summer, it would be distinct from a certification but cover the essential elements of infection control and prevention in long-term care settings.

Another major issue? Certified IPs earn more than 25% more than non-certified peers, according to APIC. Many nursing home workers who earn IP certification are drawn to other healthcare segments, where they are almost certain to earn more money.

Stone found turnover among nursing home IPs was 41%; greater IP turnover was associated with receiving an infection control citation.

IP salaries ‘pay for themselves’

In addition to being tasked with running antimicrobial stewardship programs that could lower drug resistance, Burdsall said a well-trained IP could also organize and track vaccine efforts of all kinds, monitor water management to cut the risk of Legionnaires’ disease  and ensure devices are properly sanitized to prevent device-acquired infections. They also should lead QAPI efforts as part of an interdisciplinary team.

The possibilities are limitless, but an IP needs time to visualize the threats, research mitigation strategies and build an organization-wide response backed by healthy buy-in. Given those resources, IPs’ salaries should eventually pay for themselves in reduced infections and hospitalizations and improved quality of care, Stone said.

“I know sometimes nursing homes are running on low margins, and some small nursing homes don’t want another full-time position,” she said. “But they’re going to have to see the value. If not, people will have died because of it.”

More regulation than ever

With CMS insisting it will maintain a focus on infection control even as routine inspections resume, facilities can’t wait to act. CMS officials have said as much this year, repeatedly urging providers to name IPs prior to the agency’s final announcement. 

A highly qualified preventionist, whose efforts are well-documented and marketable, will appeal to potential partners and “very sophisticated” consumers, said Donna Nucci, manager of infection prevention for Yale New Haven Health and head of an IP consulting business.

An IP serves a critical role in the annual risk assessment, which should inform programs to protect residents and staff, another important consideration given the Occupational Safety and Health Administration’s new focus on skilled nursing facilities.

Still, Nucci said she doesn’t know of a single nursing home with a full-time IP. 

She had expected hiring of IPs at all long-term care facilities to take up to 10 years, but COVID-19 caused an acceleration.  What’s happening now is similar to what she witnessed in surgery centers during the healthcare-associated infection crisis around 2000.

Stone remembers well those calls to increase acute care’s infection control knowledge through the addition of dedicated specialists.

“IP nurses weren’t considered key players,” she recalls. “The change happened when hospitals started having to report their infections.”

COVID-19 has ratcheted up similar data reporting pressure on skilled nursing, with some states moving to make all disease outbreak information highly public.