Federal strike teams and quality improvement contractors, acting in expanded roles, helped reduce the risk of COVID-19 infection by guiding interventions at more than half of all U.S. nursing homes, said officials with the Centers for Medicare & Medicaid Services.

Efforts to align quality improvement with the agency’s enforcement work put needed “boots on the ground” and sped up responses, agency leaders said at the virtual CMS Quality Conference on Wednesday.

Quality Improvement Organizations have worked with about 8,000 nursing homes throughout the crisis, including about 3,330 that were in the midst of a “major” outbreak, said Anita Monteiro, an acting director in the CMS Center for Clinical Standards and Quality.

Strike teams, meanwhile, were deployed in response to SNF requests or governor or state referrals, focusing on facilities that had 30 or more resident cases in a week. Between July and November, they served 96 facilities in 30 states.

The strike teams’ goal was to implement actionable changes within 24 to 72 hours, said Karen Tritz, director of the Survey Operations Group for CMS’ Center for Clinical Standards and Quality.

“The speed and the enterprise of the response really mattered,” Tritz said. “The preparedness was critical, but it also needed to be evolutionary and responsive.”

Her teams found that facilities that had prepared fared better during the pandemic, noting specifically the benefit of using tabletop exercises to simulate outbreaks on a massive scale. But Tritz and Monteiro also explained that it was often “the little things” that mattered in terms of breaks in infection protocol.

Among the lapses addressed by strike teams and QIOs: disinfectants applied without enough time to dry; inattention to areas where staff congregated, such as vending machines; and lack of hand sanitizers placed outside patient rooms.

Upon arriving at a facility, they used observation and data to inform mitigation strategies, much of that data collected through recent state or federal surveys.

Successful strategies revealed

Several nursing home administrators, state health officials and nursing home leaders on Wednesday shared their success partnering with QIOs and using other, existing quality improvement tools.

In Missouri, a nursing home that suffered a 57-person outbreak still reported 100% hand hygiene compliance. Its QIO partner recommended an observational audit, which revealed an actual compliance rate of 78.5%. Together, they put in place a 90% goal to maintain infection control.

In Arizona, one nursing home was so overwhelmed by additional reporting requirements that its QIO starred weekly meetings between the infection preventionist and state and federal officials. A major aim was to make sure PPE goals, particularly around donning and doffing, would actually be set and achieved.

Other efforts focused on development of testing access and rapid-testing strategies and using robust infection control methods to maintain safe group dining outside of outbreak periods.

Several QIOs shared charts that showed their charges’ case counts declined after an intervention began, but the efforts didn’t necessarily stop COVID-19 infections all together.

“It is very challenging to keep it out of the facility entirely as it is spreading across the community,” Tritz acknowledged, echoing observations found in multiple studies. 

Monteiro said the work has reinforced the idea that providers and regulators need to keep an open mind and be flexible in working together during crises, while also ensuring adherence to basic foundations through both standard and innovative practices.

“The pandemic has really underscored the need for continuous, laser-focused attention to infection control in nursing homes,” she said. “Aligning quality improvement with enforcement work has been impactful.”