Targeting a silent killer

The Centers for Medicare & Medicaid Services is embarking on an ambitious infection control pilot project to explore best practices inside nursing homes, and between them and hospitals.

The agency’s Center for Clinical Standards and Quality/Survey & Certification Group jointly presented the program to state survey directors in late December 2015. It’s a three-year effort to improve the assessment of infection control and prevention regulations in nursing homes and hospitals, and during transitions of care. Ten pilot surveys are being conducted this year in nursing homes. 

A larger number of nursing homes and hospitals will be jointly surveyed by a yet-named national contractor in 2017 and 2018. No citations will be issued to pilot participants. CMS hopes the effort will lead to better surveyor tools and recommended practices, including care transitions and antibiotic stewardship.

While the Centers for Disease Control and Prevention recently acknowledged the industry has made progress in reducing healthcare-acquired infections, recent incidents such as the Ebola outbreak exposed the need for more aggressive efforts to focus on vulnerabilities like care transitions and antibiotic resistance. The agency recently reported that up to 75% of antibiotics prescribed in nursing homes are done so incorrectly. Late last year, the CDC released its long-awaited guidelines in “Core Elements of Antibiotic Stewardship for Nursing Homes,” which was modeled closely on a similar document it released in 2014 for hospitals.

The presence of Ebola stateside last year “was a real system challenge,” Shari Ling, M.D., deputy chief medical officer for the Center for Clinical Standards and Quality at CMS, tells
McKnight’s. “And it proved to us how important a team approach among facilities and local, state and federal programs is needed.”

What has top health officials most concerned these days are widespread issues like urinary tract infections and potentially deadly intestinal problems caused by the clostridium difficile (or C. Diff.) bacterium — both of which are becoming increasingly harder to treat and cure because of antibiotic resistance. 

“We have a system that’s connected by way of the patients we serve, so all of our efforts to combat HAIs in acute and post-acute care settings also are influenced by what occurs in long-term care settings,” Ling adds. “We now know that as many as 300,000 people die from infections in nursing homes each year.”

Add to the dilemma an increasing incidence of sepsis, “a very serious problem” in long-term care facilities, says Tom Edmondson, M.D., a geriatrician and physician director for Philips Hospital to Home. “Both short-stay and long-stay patients are at risk.”

The company is working with leading healthcare organizations such as Cone Health, Mayo Clinic, Mercy and Aurora Health to develop solutions to improve patient outcomes for those who may be at risk of sepsis.

“With regard to transitions of care, the expectation of robust infection control practices will enable a more effective prevention of the spread of infectious organisms,” Ling adds. “It’s about communicating what facilities need to know if a patient presents with MRSA or some other type of infection that is highly resistant and sharing that information so that the patient can be best managed in the next setting.”

Ling stresses that while antibiotic-related outcomes will be closely monitored, a broader outcome is at stake. 

“Improving antibiotic prescribing practices is an important part of care that’s delivered in long-term care settings and nursing homes, but it is also just part of the solution,” she adds. “Robust infection control and prevention practices are equally important, as are identifying key professionals and infection control specialists in pharmacy and other areas as part of the stewardship programs. It’s going to be important to be able to know what your infection rates are and to view and react proactively on the data that comes from your own facility.”

Ling stresses that the “spirit of what is proposed” will be the expectation that facilities take a person-centered approach to resident care. 

“It’s really about a facility-level approach, the infrastructure required, the actual implementation of what one would survey to meet the conditions of participation so that we enable robust infection control practices,” she adds.

Profession’s reaction

A lot can happen in three years, but initial reactions to the ambitious plan have been mostly positive, particularly at the provider and vendor level.

Joel Rich, director for long-term care and alternate care at PDI Healthcare, says the new program “is an outstanding example of how the extended care market is now taking a more proactive approach to an increasingly regulated environment. The focus and realization that increased efforts must be initiated to reduce the number of healthcare-associated infections should be looked at as a positive step.” Rich adds that one area of interest he will be closely watching is whether the program leads to substantive changes in nursing homes’ daily routines, or reveals any “discrepancies” in success rates geographically, or between independents and chains.

Adds Edmondson, “These programs help get important conversations started, and improving patient safety and developing a more systematic approach to care is always a top priority for key healthcare stakeholders from healthcare systems to vendors.”

Established infection prevention and control programs (otherwise known as citation tag F-441) have been in the top 10 most frequently cited nursing home deficiencies for the last 10 years, notes Patricia Howell, RN, a member of McKesson’s Clinical Resource Team. 

“Hopefully, having additional focus on this area will bring improvements and higher quality outcomes for residents,” she says.

“We think that collaboration of CMS and CDC will be positive,” says Holly Harmon, RN, senior director of clinical services for the American Health Care Association. “It’s nice to see that cross-continuum is being explored.” Harmon adds that AHCA welcomes efforts particularly around appropriate use of antibiotics “because it speaks to the issue of rehospitalizations from infections. It can start in the hospital. It can start in the nursing home. It can start at home.”

Mary Madison, RN, RAC-CT, CDP, a clinical consultant, long-term care/senior care assisted living for Briggs Healthcare, believes the attention on long-term care is long overdue. 

“It’s about how we prevent and manage infections in these brick-and-mortar facilities, as well as when an individual moves between these facilities,” says Madison, a 40-year career nurse. “I have seen my share of infections during my long-term care nursing years bedside and have been on the frontline in fighting to prevent the transmission of these infections to, from and between residents, staff, families, visitors, etc. 

“I’ve experienced residents being hospitalized and returning with an infection that didn’t start here. I’ve experienced too many instances of having to isolate residents in a nursing home and all the issues that come with that. I’ve sent residents to the hospital with pneumonia, UTI, etc. and had them return with a different type of infection.”

Leniency appreciated

Harmon adds AHCA favors the program’s non-punitive nature. 

“An educational environment is far more conducive to learning and true quality improvement, and will produce better outcomes over a punishment/citation approach that we’re more familiar with the survey process,” she observes. [While the program will be free of citations, referrals nonetheless will be made to the CMS Regional Office if any Immediate Jeopardy deficiencies are found, CMS states.]

Cheryl Carver, LPN, a product specialist for Gentell, says she believes “the long-term care arena already feels scrutinized and under a microscope. Conducting a program such as this without citations will be much more accepted and positive.”

Industry advocates are a little more guarded in their enthusiasm.

“We certainly support and recognize the importance of efforts to improve and enhance infection control in care transitions and in nursing homes,” says Cheryl Phillips, M.D., senior vice president of public policy and health services for LeadingAge. “However, it also should be noted that while nursing homes do continue to face challenges in this area, the emphasis on improving related care and practices has been ongoing and there are fairly extensive requirements and guidance regarding infection control and prevention programs in the current regulatory structure.”

Phillips adds that any punitive undertones could doom the joint CDC/CMS pilot. 

“We can’t just drive excellence with a survey hammer,” she emphasizes. “This is not going to work if it is just another CMS ‘enforcement.’ Rules will not drive meaningful change. Resources, training and standard reporting tools, will be what is needed.”

While the program is comprehensive, “the concern is that the worksheet for the pilot is based upon proposed revisions to the CMS long-term care requirements,” says Linda Greene, RN, president-elect for the Association for Professionals in Infection Control and Epidemiology. 

“Although this increased attention to long-term care is welcomed, there is concern over the cost and resources needed to implement these changes, as well as ensuring that there is a reasonable time frame for implementation,” adds Greene, also the manager of infection prevention and control at University of Rochester Highland Hospital.

The draft pilot program addresses such “programmatic issues” as a formal infection prevention program that includes standardized surveillance, an annual risk assessment and an “antimicrobial” stewardship program, as well as requiring a professional with formal training in infection prevention and control whose major responsibility is infection prevention, Greene says.

Vulnerabilities addressed

The CMS/CDC pilot likely will only shine a spotlight on the fragile spots healthcare experts have long known about among nursing homes. Two of the most glaring are understaffing and money. 

“One of the greatest potential weak spots is the fact that these facilities are under-resourced,” says Greene. “The staff person responsible for infection prevention often wears multiple hats and may not have the time or resources to implement a well-functioning infection prevention program which coordinates all activities related to surveillance, prevention, and control of infections.”

Nathan Gaubert, manager of research and new product development for Spartan Chemical Company, says short-staffing creates a need to hurry. 

“This rush can lead to some major infection control deficiencies and cross-contamination. Chemical disinfectants need specific amounts of dwell or contact time to work as intended,” he says.

Another potential weak link is housekeeping, says Brandi Whiteley, innovations director of clinical services for E-Mist, which offers a mobile cordless electrostatic disinfectant application system. Yet another vulnerable spot is poor hand washing, adds Elaine McGowan, RN, vice president of clinical affairs for DermaRite Industries. 

Even when facilities add sanitizing dispensers to help hand hygiene, administrators should keep in mind that it is “not necessarily a numbers game,” says Tom Bergin, marketing director for the Away-from-Home Professional Hygiene business at SCA North America

“There should be a strategy that involves making dispensers more visible and more accessible by understanding resident and staff walking routes,” he says. Nursing stations are challenging due to high levels of traffic.

“When developing a dispenser placement strategy for nursing stations, it is important to think beyond the station itself, and consider extended areas such as walking corridors and typical paths into residents’ rooms,” Bergin says.

Whether it’s hand washing or infection rates, some administrators see these problems as opportunities in the making. 

“I don’t really see vulnerabilities, but more opportunities to do something better,” says Snipes, whose Denver-based Holly Heights Nursing Center recently reduced urinary tract infections dramatically. Efforts included a near 70% reduction in use of antibiotics. Snipes achieved those results by taking a surgical versus shotgun approach to treating UTIs with narrow spectrum meds, instead of the conventional broad-spectrum antibiotics.

“I don’t look at it in terms of infections being a weakness in nursing homes,” she says. “When we know better, we do better.”

Snipes is now taking the lessons learned with UTIs and is applying them to reducing respiratory infections.

How SNFs can prepare

CMS officials say the industry will learn much of what will be expected as the pilot runs its course over the next three years.

In the meantime, experts aren’t short on advice. Snipes advocates a well-trained staff and a passion for quality assurance performance improvement projects like she undertook for UTIs. Greene advocates facilities to undertake a gap analysis and shore up infection control weak spots.

Gaubert advises managers develop a thorough checklist of all surfaces and areas that need to be cleaned and disinfected, and ensure the work is completed.

“We would suggest nursing centers review their current infection prevention and control program, ideally with a multidisciplinary team but at a minimum [with] the medical director, director of nursing, administrator and consultant pharmacists,” adds Harmon. 

Harmon and others also strongly encourage operators to commit to memory the CDC’s antibiotic stewardship guidelines.

It’s part of an approach that will make the pilot program, and other infection control efforts, fly.