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By Joel Landau
Because they house a population that is at increased risk of contracting the coronavirus, skilled nursing facilities have been forced to closely monitor their infection-control procedures during the COVID-19 pandemic. Are they doing all they can? Is the approach consistent throughout each facility — or, as is the case with The Allure Group, which has six centers in its network — is it consistent from one building to the next?
These are among the many challenges SNFs have confronted during this healthcare crisis.
Another would be walking the fine line between maintaining social distance among residents while at the same time helping them avoid social isolation, which has been found to be a health risk for people living full-time in nursing facilities. Residents have always lived, eaten and interacted in shared group environments, typically indoors. Now, that’s not the best idea. But how does a facility walk the line? How does it balance the need for distance and the dangers of isolation?
Additionally, there is the fact that staff members often provide close, intimate services to residents and support many different residents. In fact, some nursing facilities share staff members.
Staff members are typically trained in resident care but specific skills around infection control may be lacking. This was especially true in the early days of the COVID-19 pandemic. Staffers were often overextended, or may have been working with too many people or at too many facilities. They were also given procedures that were ideal for controlling infection at one facility, but not another. As an example, some procedures that were deemed useful in hospital settings were not always applicable to the SNF context.
Given the enormous stakes, changes have been implemented on the fly and best practices reevaluated, in the interests not only of the present but future outbreaks of viral or bacterial diseases.
SNFs have in many cases formed separate, highly trained infection-control teams to develop and implement new policies and provide clear training to all staff members. They have changed the ways that staff members interact with residents, restricted the number of residents they support and provided hard and fast principles for best practices in nursing facilities.
Infection-control programs in a skilled nursing facility aim to minimize the risk to each resident, reduce the risk of transmission between residents and between residents and healthcare workers and reduce the risk of infectious spread through the use of shared medical devices, procedures and treatments. Different residents may face different levels of vulnerability and require different levels of protection. Those who live permanently in a facility may have additional vulnerabilities, compared to those admitted for a short period of skilled care.
Helpful protocols include addressing hand hygiene, droplet precautions, contact precautions and the use of personal protective equipment (PPE). Past infection-control procedures in nursing homes often focused on preventing gastrointestinal illness or more common bacterial infections. Some of the techniques that successfully protected against these illnesses were less protective in the case of coronavirus, drawing attention to the need to improve hand hygiene and personal protection for all residents and staff. The CDC provided assessment tools to help nursing facilities adapt their procedures to prevent the spread of COVID-19.
The federal government and national agencies have emphasized the importance of infection control in nursing facilities as well. Past CDC guidelines focused on the importance of cutting down on unnecessary antibiotic usage in order to prevent the spread of antibiotic-resistant bacteria, as well as isolation and quarantine protocols, especially for contagious illnesses like influenza and norovirus. With the rise of COVID-19, the focus has also spread to increased usage of personal protective equipment, including N95 masks. Typically, these types of medical masks were less frequently used in nursing homes, but they have been important to minimize the spread of coronavirus.
New regulations from the Center for Medicare and Medicaid Services specified that inspections would be ramped up, especially in facilities with seemingly uncontrolled spread of COVID-19, with consequences imposed for noncompliance.
On the other hand, the Department of Health and Human Services announced $2 billion in funding to incentivize infection-control programs in nursing homes. In order to receive these incentive payments, nursing homes were required to achieve a COVID infection rate lower than the rate of infection in their county. The payments would also be distributed based on measures of infection and mortality and would be required to be directed towards expenses for infection-control improvements.
Nursing home executives have reported key takeaways from the experience with the coronavirus pandemic. Increased staffing resources has been a critical part of infection control. When overworked staff must deal with too many residents, infection-control procedures can easily fall by the wayside or even become impossible to maintain. Therefore, higher investment in staffing resources, engagement and training has been a major predictor of success in controlling the pandemic.
Technology has also provided real hope in revolutionizing infection control in nursing facilities, often with relatively small and highly achievable changes. HVAC systems in residents’ rooms can be adapted to transform them into negative-pressure isolation spaces, a technique that has been of enormous value in forestalling the spread of an airborne virus.
This is not the only way in which technology has pointed to a forward-looking path to control infections beyond today’s COVID-19 pandemic. Electronic medical systems provide substantial amounts of data that facilities may use to improve outcomes. Electronic medical records can point to a developing problem before it is clear to staff and administrators, prompting earlier interventions that can prevent negative outcomes. Data analysis and management – and the early warnings they can raise – may help nursing facilities prevent and manage future outbreaks successfully.
The coronavirus pandemic has been a tremendously challenging time for nursing facilities and for our country and world as a whole. It has also illuminated the importance of infection-control procedures that have helped to stop or minimize spread and save lives. These procedures and approaches, including innovative technical options, may continue to improve health and safety in nursing facilities for years to come.
Joel Landau is founder and chairman of The Allure Group, a network of six New York City-based skilled nursing facilities. He has served as a member or an advisor on a number of boards and committees, including the Medicaid Managed Care Advisory Review Panel (MCCARP), NYS DOH Preventative Health and Health Services Block Grant, NYS DOH Task Force on Long Term Care Financing, and the Brooklyn Chamber of Commerce.
Joel Landau, is founder and chairman of The Allure Group, a network of six New York City-based nursing homes.