Costly Endeavors: New Era of Nursing Home Infection Control Comes with High Pricetag

Infection prevention and control is always front and center at nursing homes and ever more so now in the midst of growing concerns over drug-resistant superbugs, such as Candida auris.

While these infections are on the rise, a change to Covid-era protocols has meant less money for infection prevention efforts. However, clinical experts say that this shift has kicked into place an “infrastructure change” for infection prevention, and it doesn’t help to have fewer federal subsidies in place. Efforts to curb antimicrobial use and improve infection control cannot simply be implemented with common sense measures and require more staff and different protocols – all costly endeavors. In fact, continued funding towards IP initiatives is now needed.

“I think we need to be very aware of the fact that these programs are not really cost neutral,” said Dr. Swati Gaur, medical director at New Horizons Long Terms Care Facilities in Georgia. “In order to have a good [infection prevention] program, you have to invest in creating the infrastructure.”

Infrastructure associated with infection prevention includes hiring an infection preventionist, who in turn works in collaboration with the chief medical or clinical officer as well as the pharmacologists and other staff members to discuss disease-related data at regular meetings, such as those dedicated to Quality Assessment and Performance Improvement (QAPI). The clinical team then designs or modifies protocols, such as those used to curb antimicrobial use, after examining this data and each nursing home’s unique disease profile. 

There are, of course, costs related to these initiatives, but to top these costs, there are expenses stemming from equipment and protective gear, as well as extra labor when a nursing home reports a contagious illness.

And dedicated, full-time infection preventionists – often missing from small operators due to costs in hiring one – are the lynch pins in running a smooth operation at a time when long-term care facilities are under scrutiny to cut back on antibiotic overuse and curb infections, explained Gaur, who is also affiliated with AMDA-Society of Post-Acute Long Term Care.

According to the Centers for Disease Control and Prevention (CDC), not only is multidrug-resistant organism (MDRO) transmission common at skilled nursing facilities, but it has contributed to “substantial resident morbidity and mortality and increased healthcare costs.”

And so, infection prevention, while itself bearing costs in the near term – from protective gear to extra labor – is important in bringing costs down in the long run, experts said.

The cost breakdown

For starters, staff wear personal protective equipment (PPE) for enhanced barrier precautions, such as gowns, gloves and surgical masks. Latest figures for these costs related to PPE are estimated to be $12.45 per patient per day in health care settings in 2021, according to group purchasing organization Premier Inc.

This figure, while high, is a drop from $20.40 per patient per day at the height of the pandemic.

At the height of the pandemic, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said that the cost of PPE was “considerable” and nursing homes spent roughly $20 million on PPE and staffing alone at the time. These are the latest figures on PPE costs, AHCA said, and despite costs coming down since then, high inflation hasn’t helped recently.

Moreover, the industry’s largest trade group was also quick to point out the difference in protocols when dealing with Covid versus rising drug-resistant fungal and bacterial infections, including C. auris. And this might mean additional costs.

“Current CDC guidance recommends Enhanced Barrier Precautions (EBP) for any resident with colonization of a Multidrug Resistant Organism (MDRO), such as C. auris. We have heard from facilities that this implementation will be costly to implement due to increased use of PPE,” an AHCA spokesperson told Skilled Nursing News.

And another change since pre-pandemic days is the higher acuity of patients in nursing, which forces nursing homes to take on extra precautions, in turn driving up costs of infection control even more.

“Nursing homes these days have really complex patients … they are almost a step down in [acuity] from the hospital. So we have a higher number of these super complex patients that are frequently going back and forth to the hospital and would qualify for these enhanced barrier precautions to be put in place,” Gaur said.

Moreover, hiring an infection preventionist – a specialized role with average salaries more than the nursing staff’s – isn’t always an option for smaller nursing homes both due to affordability and labor shortages, which have cut into profits.

According to Salary.com, the average cost to hire an infection preventionist – not necessarily for nursing homes – is $104,615 as of March 28, 2023, but the salary can range from $91,279 to $119,451. Many smaller nursing homes, especially those not tied to a larger organization, are unable to afford a dedicated infection preventionist, Gaur said, but the role is absolutely key and unable to be successfully executed without the proper training and education.

Assessing the antimicrobial burden

Costs may also be indirectly related to the time required to implement some infection control programs, including assessing the antimicrobial burden. It takes time to collect data and the entire clinical team to assess this data.

Antimicrobial stewardship programs — which advocate for more responsible use of drugs to prevent resistance — are administered based on the nursing’s home’s data profile on disease and drugs administered, and bear underlying costs related to staff time.

“For the antimicrobial stewardship programs there is the staff time needed for tabulation of data, of creating this actionable data and then doing … improvement cycles. And this can only happen if we account for the staff time,” Gaur said. “Every month looking at the data on the number of infections, number of resistant infections, we’re also looking at the use of antimicrobials and the antimicrobial burden.”

This also means analyzing “antibiograms” – reports generated by labs, which are like a snapshot in time that help provide guidance on the best use of antimicrobials.

While exact costs of running each program can vary, all this requires time, money and specialized roles to be deployed.

“So these are not cost neutral programs. These programs need staff time; [they] increase staff time,” said Gaur. ”How can you support this with the current staffing that we are seeing?”

Costs need to be subsidized

With the end of the PHE, some costs will not be supplemented by the federal government.

“They cut PPE money,” said Gaur, explaining that this really impacts such protocols as having receptacles for clean and dirty PPE and the disposal of that dirty PPE – this being one example of the costly protocols not subsidized. “They need to [include] accounting for all the PPE that we are going to be using right now [because] it’s a huge amount of infrastructure change that we’re talking about and a huge amount of staff time.”

Without the extra staff, infection protocols will falter, she said.

“If you don’t get staff time and staffing that would support this, an effective program cannot stand,” Gaur said.

Containing super bugs also means extra beds, psychological costs

Proper staffing and funding are especially crucial to minimizing threats from superbugs, but another cost is beyond monetary – that of the psychological burden from disease.

“They’re harder to treat,” Deborah Burdsall, an infection preventionist who is affiliated with the Association for Professionals in Infection Control and Epidemiology (APIC), said of drug-resistant viral, bacterial and fungal infections, such as C. auris. “The people that get them have to be isolated for extended periods of time because some of these just don’t go away … [It] requires not only the cost of the personal protective equipment which is expensive, but also the psychological impact.” 

Isolation also means that residents have to be placed in private rooms.

“There are a lot of facilities that are really challenged if they have to put all of the residents in private rooms,” said Bursdall, who has been an infection preventionist in long-term care since 1991. “There’s the economic cost, and then there’s the psychosocial cost for your residents … the cost of the pain of having infection because we all know how crummy you feel when you have an infection.”

And at the end of the day, while hiring an infection preventionist may be costly in itself, it is what can in the end bring down some of the burdens, she said.

“The infection preventionist steers the ship, making sure that the infection prevention strategies, policies and procedures are being implemented, which clearly can save lives and can cut down on the cost of things if you don’t have people that are infected or colonized with some of these scary bugs,” Burdsall said.