For Nursing Home Infection Control to Improve, Regulations Need to Prioritize It – While Supporting Facilities

Dr. Buffy Lloyd-Krejci knew nursing homes had infection control problems well before a global pandemic put them in the spotlight.

That’s why she started her infection control consulting firm, IPCWell, based in Arizona. She was introduced to the challenges of infection in nursing homes while working on a collaboration between the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) to help skilled nursing facilities improve their reporting Clostridioides difficile (C. diff) infections.

It “was quite eye-opening” in terms of showing her the challenges nursing homes faced in controlling infection. Those difficulties range from a lack of eduction to insufficient resources to a regulatory system that was not primed to address infection issues until recently. In fact, she estimates that until the last year or two, infection control in nursing homes was less of a regulatory priority.

When COVID-19 hit the U.S. in spring of last year, that had devastating consequences.

Lloyd-Krejci worked in nursing homes all over the country throughout the course of the pandemic, and still does consulting, including stints with Doctors Without Borders in Detroit and Houston during their missions in U.S. nursing homes. She joined Skilled Nursing News’ Rethink podcast to talk about her work in nursing homes both before and during the pandemic, and why SNF regulators need to take cues from hospital oversight in order to make real improvements.

Excerpts from the podcast, edited for length and clarity, are below, and if you like what you hear, be sure to subscribe on iTunes, Google Podcasts, or Soundcloud.

Why did you decide to focus on infection control in nursing homes?

Before the pandemic, and really what motivated me to start IPCWell, was that I was working on a national collaborative with the CDC and CMS supporting nursing homes across the country to report an infectious disease known as Clostridioides difficile infection, or C. diff into the CDC National Healthcare Safety Network (NHSN).

We were having nursing homes report and collect C. diff data, because there really isn’t a lot of actual standardized surveillance for infectious diseases, and the actual estimates of infections in nursing homes are between 1 million and 3 million infections occurring every single year, resulting in 380,000 deaths.

I like to tell people: That’s over 1,000 people dying every day in nursing homes due to infections. So this was quite eye-opening for me, having a background in acute care and also in research. I wasn’t as familiar with this problem in nursing homes, that it wasn’t as well understood. So this really opened my eyes and motivated me to really want to do more.

So I stepped out, I created IPCWell, and then started targeting facilities to help them start collecting infectious disease data.

What I’ll say is that I was a little naive in thinking that they were ready for that, because as I started going to more and more facilities, I realized that data surveillance was not– they weren’t ready. I was happy if they would wash their hands basically, at that point, versus having them actually collect data.

It was a step that is necessary, but they needed to start with the basic infection control practices first.

What were some of the reasons for that lack of readiness? Was it resources, or the place nursing homes have in the continuum of health care?

Traditionally, the long-term care facility has been a bit behind with some of our practices. It wasn’t until 2016 that CMS actually mandated that every SNF that is certified by CMS in the United States was required to begin implementing an infection control program.

So we’re just talking a few years ago. In 2017, they were required to have an infection control program, in 2018, an antibiotic stewardship program, and then November 28 of 2019 – just a few months before this whole pandemic started – they were required to have a part-time infection preventionist on site.

They weren’t ready because it hasn’t been a priority. Now, we’ve always had infection control practices, but it hasn’t been a priority in a sense that we’ve really focused on it and worked on it proactively. The reason being is because within this healthcare setting, it’s heavily heavily regulated. So the facilities will focus and target on those areas that are demanding the highest attention from regulation, whether that’s fall risk or pressure injuries or antipsychotic use.

Whatever area that the regulations are really focused on, this is where the nursing homes’ attentions are. And so it wasn’t until really the last year or two that infection control has been a higher priority.

Let’s go back to the last year, then. What did you see on the ground in facilities as COVID hit, and what were some of the challenges and obstacles around infection control for COVID-19?

When we first started hearing of this novel virus from China, because it was being described as an airborne virus, my first thought was: In SNFs, we don’t take care of patients that have airborne infections, such as tuberculosis or measles. Those require a specific protocol, they require negative air rooms, they require N95 respirators, which you have to be fit-tested. And we don’t do that. All those patients are cared for in the hospitals.

So first I was hoping that it was going to be contained, because it seemed at first that we had some tracing that was occurring. But then when we saw the nursing home outbreak in the Kirkland, Washington nursing home, I knew that we were headed for some trouble.

Early on, what I saw, and what the country saw, was just the demand for personal protective equipment, or PPE. When governors are bidding over getting PPE, we know that the nursing homes are going to be challenged with it. If they didn’t have a hospital partner, or part of a larger corporation, they definitely suffered. Many, many nursing homes that I worked with, or suffering greatly without the PPE. Some of them still are.

And also just the training; I mean, our health care system was not prepared. So you can imagine with infection control not as high of a priority in long-term care until just a few short months and years before, they were definitely unprepared.

So it was a shock to the system. We didn’t have the expertise, the training, the equipment. And when states such as New York started requiring nursing homes to take residents with COVID, we definitely felt the impact. That’s where we saw a lot of the challenges start happening, because we didn’t have what we needed.

Can you go into some of the work that you did with nursing homes during this time, given those challenges?

Through about March and April, I was doing mostly remote work. The nursing homes had been mandated to shut down … and quite frankly a lot of the nursing homes that I was working with, they had maybe one or two cases, but they weren’t in in hot water.

It was after the birth of my grandson in May, I was in Tennessee, and I received an email that Doctors Without Borders, was looking to begin a mission here in the United States in Detroit, and I knew it was my time to get out into the middle of it. So I had responded to their request, and within days, I was being interviewed and going through the actual process of medical screening and whatnot.

I joined the team in Detroit in June, and I worked with the Doctors Without Borders team. It was their first U.S. mission. They are an international humanitarian group, and because a lot of borders were closed, they thought it’s time to help the U.S. here at home.

It was a team of staff that had worked a lot on Ebola in the field, and so I was quite honored to be able to work with such esteemed colleagues. What I soon learned was that none of them had long-term care experience specifically in the U.S. They had taken a program that had started in Belgium, and then tried to adapt it here into Detroit. And we were able to do that with some success. But within days of being on site, I knew that we had to take a different approach with our nursing homes.

Fortunately, the team is so fluid, that we basically create a program for the needs of the community. We started going on site to these nursing homes, and realized very quickly that some of them, were going to need more than maybe one visit. So we would come in, we would do an infection control assessment, we would do a tour of the facility, talk to them, listen to what they needed, and then write up an assessment, or our recommendations.

But it became very apparent that many of the facilities would need more. Since I was the only one trained in this specialty, my role became what we call as being embedded into the facilities, where I would go on site for about three to four hours a day, per one facility, and just work with the staff.

We found that the primary staff that I worked with was actually non-clinical. It was the environmental services, as this is the front line for the infection control, where the housekeepers aren’t always trained very well. And they’re literally going into every single room, cleaning the rooms, and they can also be very responsible for transmitting the virus, if they’re not appropriately cleaning.

I would get in there with them, I would clean toilets with them, I would demonstrate how to put on PPE, how to take it off. Just to give you an example, I was on site in one facility and the housekeeper – I said, “Will you show me what you do for this room?” It was a COVID positive room, and she just walked right in the room and started cleaning. She didn’t put PPE on she didn’t have her proper equipment, because she didn’t really understand this, the seriousness of it.

We really went to work very, very heavily in supporting that non clinical staff, as well as the clinical staff – we would conduct classes and provide services – but even even that was more targeted toward the certified nursing assistants, or those staff that just don’t have as much training as as the nurses do.

Given what you’ve seen over the course of COVID-19, what works or doesn’t work in terms of the regulations for supporting infection control in nursing homes?

We definitely need regulations and we need oversight. There’s no doubt about that. The problem, however, is that the oversight that is provided in nursing homes has been designed to be punitive in in its whole structure. It is not meant to be collaborative. It is: We’re going to come in, we’re going find what you’re doing wrong, and we’re going to write up a report, we’re going to cite you, we’re going to fine you, and you’re going to fix it.

It’s a huge burden on the nursing homes. If we had more of a collaboration such as we do in in our hospitals – where the accrediting bodies actually come in and offer solutions and support, it would be a whole different story.

And within this pandemic, to me, it has been completely inappropriate. Based on the feedback that I’ve received from hundreds of people in nursing homes, it has been a waste of time and actually completely devastating to the industry. What I mean by that is CMS announced early on that they were going to discontinue the typical annual survey process, and they were going to focus on COVID infection control, which sounds great.

But if a nursing home was in an outbreak, then that would target a survey process. And the surveyors would come in during a facility’s most vulnerable time. Remember, they didn’t have what they needed. Oftentimes, during an outbreak staff are out sick, or they’re out on leave, or they’ve quit, because they’re afraid of being there.

So [the surveyors] are coming in when you’re low-staffed, you’re stretched at your capacity, you’re very stressed out trying to implement guidance that changes from day to day to day and trying to keep track of all the updated guidance. And then you have the surveyors come in who are often rude, who are often unsympathetic.

Also the the surveyors are not as well-trained as they used to be. Where they used to do week-long trainings, and intensive training, and then have mentors, now all their trainings done online. So they’re not actually equipped or skilled to really understand some of these practices. And they’re very nit-picky, so they would maybe cite somebody for putting PPE on wrong or those easier-to-identify solutions that that can just happen, not because we don’t understand it, but because we’re in the middle of a crisis.

Then the facility has a citation, they have to do a plan of correction. They have days and days that they have to devote to filling out paperwork to demonstrate that they have remediated the problem, which takes away from the staff, which takes away from resident care – again, in the middle of their outbreak, in their crisis.

And they don’t offer solutions, they don’t offer help. So it really is not a time for a regulatory system to come in and say: Here’s what you’re doing wrong. We needed more of a collaborative approach and support, especially in this population where they’re already under-trained, and they didn’t have what they needed. It’s really been defeating, and quite frankly, in the industry, the morale is so low right now.

What would you want to see change about infection control in SNFs and the regulations and approach to it?

You know, it was hard for me to get my messaging out; I was preaching about the harms and deaths with infection before COVID, and because there were other priorities at the nursing homes were facing, I was often not listened to or turned away. Now, of course, with this pandemic, people realize that infection control is a huge priority, not just for COVID. I mean, we have multidrug resistant organisms and all these other infections in nursing homes, and so we have a lot of work to do.

I am hopeful that the the silver lining of this is that we can really take a look at our infection control programs, and model what has been done with our acute care facilities and having nationally funded infection control quality improvement projects, that help us begin to work proactively in mitigating these harms.

Our loved ones don’t have to die from an infection that we give them in a health care facility. For years, even in hospitals, we thought that was normal, and it’s not. And we’ve been able to demonstrate over the last decade, with quality improvement projects that we can proactively reduce these infections and save lives.

So this is my hope within the nursing home, that we can begin these projects. But it’s going to take funding, it’s going to take national support, and collaboration, and I believe we’re heading in that direction.