As nursing homes come under fire for inadequate handling of infection control, many in the industry are calling for equipping facilities with more infection preventionists, and even redefining the role.
Recently released data from Covid surges in 2020 seems to show that nursing homes do indeed need to improve in this area, whether through a designated position for infection control or otherwise.
According to a report put out by the Office of Inspector General for Health and Human Services (OIG), for-profit nursing homes made up 71 percent of all nursing homes, yet they made up 77 percent of the nursing homes with extremely high infection rates during both the first and second Covid surges. Nonprofit nursing homes made up 23 percent of all nursing homes and accounted for 19 percent and 18 percent of the nursing homes with extremely high infection rates during the first and second surges, respectively.
And even though most of those facilities identified no infection control issues in their internal surveys, government oversight agencies weren’t persuaded.
The high mortality numbers do not come as a surprise to Dr. Sahebi Saiyed, member of the Infection Advisory Subcommittee with AMDA, the Society for Post-Acute and Long-Term Care Medicine. She says the situation could have been helped by the presence of an infection preventionist.
With this in mind, the IP role is taking on increased importance for providers and industry watchdogs — but just as a staffing crisis is making it more difficult than ever for operators to fill the position and maximize the effectiveness of infection preventionists.
Heightened scrutiny
Earlier this month, OIG and CMS announced that they will take action on infection control issues in nursing homes, building on previous investigations into the skilled nursing industry, including re-examining and revising nursing staff requirements.
Further evidence is needed to determine the level and type of nursing staff necessary for today’s nursing home resident, with a focus on how the infection preventionist fits in, the OIG report stated.
“These may be nursing homes with dramatic increases in mortality, a high percentage of residents with infectious diseases, or nursing homes with other characteristics that raise concern,” OIG researchers said. “This analysis could help CMS’s efforts to effectively target its resources toward nursing homes most in need of intervention.”
Officials said they plan to reevaluate staffing requirements with a focus on nursing homes in most need of infection control intervention.
In 2016, the Centers for Medicaid & Medicare (CMS) issued requirements that nursing homes needed to designate an individual as an infection preventionist in charge of overseeing the facility’s infection preventionist program, prompting providers to look for more clarification on how to meet the guidance.
CMS requires that IP professionals have completed specialized training in infection prevention and have a background in nursing, medical technology, microbiology, epidemiology, or other related field. They are typically drawn from the licensed nursing staff pool.
Saiyed knows what it’s like to work with an infection preventionist by her side in the pre-pandemic days and without one during its peak, when infection control could have prevented deaths. And, Saiyed is sold on the role infection preventionists can play in curbing the spread of infection having weathered a C-diff bacterial outbreak, which can cause life-threatening diarrhea, at a nursing home facility without the assistance of an infection preventionist.
“We can reduce hospitalization if we have a good support system on our side,” Saiyad said. “But related to IP, I feel like we need to do much better.”
Saiyed, who also works as a medical director at Emory Healthcare, said that one of the biggest barriers to a larger presence of infection preventionists at nursing homes is staff turnover.
“We haven’t had any consistent IP [at Emory] for a long time,” she said. “But before Covid, we had someone who was there for at least a year.”
And this helped take some of the burden off her shoulders. It also allowed Saiyed to use her time more effectively. Rather than spending time on the simple education of staff, she could use her time more fully towards her role as a physician to address the medical needs of the residents.
“I had to educate everyone because we didn’t have an IP who was trained,” she said. “We had to educate every component of the nursing staff. So, I think we are very behind. I feel like now we are probably moving in the right direction.”
Evolution of the role
By 2020, the role of the infection preventionist – and their workload – became more significant during Covid-19 outbreaks in nursing homes.
In 2022, CMS updated its guidance to stipulate that each facility should have an IP on board at least part-time, with specialized training to effectively oversee its infection prevention and control program, including offering specialized training for infection control and prevention.
“I think COVID probably accelerated a lot of the focus on skilled facilities in regard to infection control and infection prevention,” Dr. Tony Hatcher, Chief Medical Officer at HillCrest Health Services said. “It wasn’t something that we were surprised that CMS had mandated from a regulatory standpoint.”
Not all facilities can afford to dedicate staff towards fulfilling the role of an infection preventionist, however.
Hatcher said that whether or not to employ a full-time or part-time infection preventionist is really dependent on the size of the facility, but for some smaller facilities, it might not be sustainable to try to have someone on full-time. Hatcher said in his experience, infection preventionists typically report to the director of nursing and work collaboratively with the rest of the team.
“There’s not enough role for them really to have a team underneath them,” he said.
Still, with Covid, RSV, and the flu impacting facilities, the role is vitally important, he said. And infection preventionists also track what kinds of infections occur at facilities and if the right kind of antibiotics are being prescribed.
Yet Hatcher said there are very few facilities employing a full-time infection preventionist on-site, and if they do, the infection preventionist is also providing direct patient care.
“The majority of them are in nursing and are providing direct patient care as well as IP so this is just an additional duty that you try to carve out of their day or another week so they can provide the services,” he said.
Saiyed said she used to advocate for IPs under her supervision to have more hours dedicated to infection prevention, but with the lack of consistency in the role, it has fallen by the wayside.
Infection preventionists are likely forced to juggle many more tasks during a time that nursing homes are confronting a labor crisis.
“They are involved in staff orientation, they’re doing education for the staffing, and then this role and they might even be asked to do something else,” she said. Ideally, she said, nursing home infection preventionists should strive to be equal to hospital infection prevention teams, especially because nursing home residents are more prone to infections.
Hiring for the role
Given the labor crunch, it’s a tough environment for hiring, and when paired with additional expertise required to fill the shoes of an infection preventionist, the task becomes harder.
Saiyed said that in her experience hiring for the position, she hasn’t been able to hire from within and find eligible candidates with the right combination of clinical and managerial experience. Moreover, the lower pay and higher workload of infection preventionists in the nursing home setting when compared to infection preventionists in hospitals often deters eligible candidates, she added.
“It’s been very difficult to hire staff in nursing homes in recent years because of the low pay. And I think they do a lot of work, but they don’t get compensated for what they work for,” she said.
Although less than ideal, her director of nursing is fulfilling the responsibilities of an infection preventionist.
As for Hatcher, he said that he tries to avoid having his DON take on the duties of an infection preventionist, although the person in the IP role needs to have similar skills.
“They have to be able to, you know, lead teams to lead projects, to be project manager, to enforce rules,” he said. “And so you can’t be just a run-of-the-mill nurse.”
As far as changing the role, industry professionals agreed that some policies and procedures might need to be re-evaluated, but the role of the infection preventionist itself could help combat rising infections in a facility.
“I don’t think that the creation of a new position is going to solve the problem,” CEO of GAPS Health Dr. Jerome Wilborn said. “That’s me as a clinician, I don’t think that’s what’s going to solve it. I think what’s gonna solve it is diligence. I think what’s going to solve it is having a clinical leader or physician who understands infection control.”
Wilborn said that perhaps enforcement of common sense measures for prevention of disease spread such as washing hands, wearing masks and social distancing can work well, and if supervised correctly can go a long way and save money as well.
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