The need for infection preventionists has never been greater, but long-term care providers remain in the dark as to how and when they will need to fit new federally imposed criteria

Last fall, Terry Burch, R.N., wrapped up an agency contract and transitioned to a permanent position at Briarcliff Health and Rehabilitation in Indiana.

But the promotion required he split his time as both a unit manager and the infection preventionist for the entire 87-bed facility —  initiating a constant struggle for balance amid the backdrop of COVID-19.

“Day to day, there aren’t any guarantees as to how I spend my time,” says Burch. “It’s heavy on both sides.”

The nation’s nursing homes are still awaiting final interpretive guidance from the Centers for Medicare & Medicaid Services that will dictate who meets the agency’s definition of an IP, how many hours they should commit to infection work and what qualifications or training they must have.

The position was mandated as part of a broader focus on infection prevention and control in the 2016 Requirements 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 related penalties — 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. CMS told McKnight’s in mid-April that it will introduce full guidance “in coming months” and that, for now, “regulatory language provides general parameters about the requirements.”

But some providers feel they 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 program 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, says 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,’” says 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.” CDC also insisted the IP be full-time in facilities with more than 100 residents, or if ventilator or hemodialysis services are offered.

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, or APIC, strongly recommends more comprehensive training that prepares IPs to earn an endorsement from the Certification Board of Infection Control and Epidemiology.

Evelyn Cook, RN, 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 says 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, Columbia University School of Nursing’s Patricia Stone, Ph.D., RN, found that just 39% of nursing home IPs had received “specialized training” and less than 3% of those held any IP certification.

A second study, published in 2020, found that nursing homes with IPs increased from 3% to 7% from 2014 to 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.

More pay elsewhere

One of the challenges is that the CBIC, 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, APIC is working to create a competency designation for IPs that work in long-term care. Expected this summer, it would be distinct from a certification but cover essential elements of infection control and prevention for SNFs.

Another major issue? 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. 

Cook says any position that requires the IP to continue in other duties, particularly nursing, will allow them to be pulled away from the infection control mission any time a colleague is sick, or more permanently in the event of a staff shortage.

“That doesn’t happen in the acute-care world, and it can’t happen here,” says Cook, who wants CMS to mandate a full-time requirement with few exceptions. 

Burch also believes the position should be full-time. While he feels supported by his employer, he’d like to spend more time training colleagues and creating programs that become entrenched in building culture. 

“COVID was at the forefront for so long, that some of the other stuff was overlooked,” he says. “There are a lot of things to be completed and rounded on that aren’t COVID, and a lot of facilities, because of the hyper-government focus on COVID, aren’t doing them.”

Time to do the job right

A dedicated full-time IP professional would maintain standards even as conditions fluctuate, and provide an additional monitoring and retraining presence in any crisis.

And another crisis will come, Burdsall says.

“These organisms that are out there, there are more of them,” she says. “It’s not just COVID.”

In addition to being tasked with running antimicrobial stewardship programs that could lower drug resistance, a well-trained IP also could 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 says.

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

CMS officials have repeatedly urged providers to name IPs prior to their final guidance. An agency official told McKnight’s that 94 related F-tags were issued in 2020 and 2021, indicating that enforcement actions are underway.

More than regulation

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

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

“It’s a very, very difficult challenge to find somebody who can deliver competent care, especially in the LTC setting,” she says, noting tech that tracks goals, prompts reporting and offers educational modules can help.

Even with assistance, Nucci believes an IP should be a licensed nurse. The role, she said, is dictated by an intense clinical focus on surveillance, followed by efforts to identify infection among residents or staff, manage those infections and educate staff.

Nucci had expected hiring of IPs at all long-term care facilities to take up to 10 years, but COVID-19 has ramped up the transition. It’s similar to what she witnessed in surgery centers during the healthcare-associated infection crisis around 2000.

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

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

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

Watching nursing home case and death counts climb a second time last fall convinced each of the IPs interviewed by McKnight’s that nursing homes either haven’t learned enough about infection control or still don’t have enough resources to protect against infection. That CMS proposed an IP position five years ago and still hasn’t given providers a full playbook is equally frustrating.

“We did know there were issues (before COVID-19), but we just didn’t do enough,” Cook says. “We cannot lose sight of this opportunity to make everyone aware that they really need more resources. Not only time, but education and support and empowerment.”