Analysis identifies significant gaps in infection prevention practices in long-term care facilities

While nearly 400,000 residents of long-term care facilities die as a result of healthcare-associated infections (HAIs), these facilities continue to lack the resources, including qualified personnel, necessary to implement adequate infection control programs, according to research presented at the 44th Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

More than 1.4 million Americans reside in one of the nation's approximately 15,654 nursing homes, according to the Centers for Medicare & Medicaid Services (CMS). Reducing HAIs is an important goal for CMS, who issued rules requiring all long-term care facilities (LTCFs) to strengthen their infection prevention and control programs. The rules require facilities to have an infection prevention and control officer, and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Public health professionals from the Tennessee Department of Health and in Washington State assessed a sample of LTCFs to determine their infection prevention proficiency using a tool developed by the Centers for Disease Control and Prevention (CDC). Of the 43 assessments performed in the two states, researchers found many infection control officers in LTCFs had little-to-no formal training and lacked foundational skills for proper infection prevention. Researchers also discovered high turnover rates with facilities struggling to retain consistent, qualified personnel to manage infection control programs.

"The findings presented here are concerning and should prompt immediate efforts to increase education and support for infection prevention programs in all types LTCFs," said Linda Greene, RN, MPS, CIC, FAPIC, 2017 APIC president. "Nursing home residents often have multiple, chronic diseases, transfer frequently between the hospital and the long-term care setting, and are overexposed to antibiotics, all of which place them at higher risk for developing infections with antibiotic-resistant organisms."

"The lack of resources and training for infection prevention in LTCFs is concerning, especially given the fact that LTCFs admit sicker patients in higher numbers than in the past," said Colleen Roberts, MPH, a researcher on the Tennessee study and an HAI epidemiologist with the Tennessee Department of Health. "These assessments confirmed our suspicions that many LTCFs suffer from understaffing and lack of appropriate infection control training, which can impact patient care."

State of Tennessee

The Tennessee Department of Health performed 23 infection control assessments in LTCFs across the state from January 2016 to November 2016 using the CDC's Infection Prevention and Control Assessment Tool for Long-term Care Facilities. Public health professionals assessed facilities for gaps in nine infection control domains, including infection control program and infrastructure, hand hygiene, and personal protective equipment (PPE). The tool evaluated infection control training, competency, and implementation of policies and practices for each domain.

In Tennessee, 56 percent of LTCFs assessed had infection control programs overseen by someone who had no additional training in infection control. On average, only 12.5 staff hours per week were dedicated to infection prevention activities. While 72 percent of facilities implemented an online competency-based training program for hand hygiene, only 50 percent provided real-time feedback to assess performance. In addition, 67 percent of facilities implemented a competency-based training program for proper use of PPE, but nearly half failed to provide feedback or observe return demonstrations to check whether personnel were donning and doffing equipment properly. More than 9 out of 10 facilities (94 percent) did not meet the requirements for an antibiotic stewardship program.

Washington State

In Washington, public health professionals performed 20 assessments in LTCFs using the CDC assessment tool. They found that while all facilities had designated infection preventionists (IPs), only 10 percent had formal infection prevention and control training. On average, IPs spent 11 hours per week on infection prevention, and many of those appointed to the role were new to the field and had limited guidance or written policies and procedures. Though 75 percent had policies in place, only 40 percent were reviewed annually. In addition, staff received incomplete training upon hire and subsequent training in most domains was even less likely one year post hire or thereafter. Only 15 to 30 percent of LTCFs conducted ongoing auditing/feedback of assessed competencies.

"Our analysis identified clear gaps in infection prevention practices and the urgent need to improve infection control infrastructure in long-term care facilities," said Dorothy MacEachern, MS, MPH, CIC, infection preventionist with the Spokane Regional Health District and a researcher on the Washington State study. "Future efforts should be directed at providing training, ongoing education, and support for IPs in these settings."