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Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today.

May 2020 Bug of the Month

Vascular access devices (VAD) are used in almost all medical, surgical, and critical care specialties, pre-hospital, hospital, long-term care, and home-care settings.

The range of catheters and devices referred to as a VADs include: peripheral intravenous catheter (PIVC), midlines, peripherally inserted central catheter (PICC), central venous catheter (CVC), tunneled CVC, subcutaneous port, arterial catheter, intraosseous device, apheresis catheter, umbilical, and ECMO catheters. As a result of VADs being used daily in almost all inpatient settings a range of healthcare professional roles share the responsibility for insertion, management, and removal of VADs. The varied interdisciplinary members responsible for one such VAD, the PIVC, were researched in a qualitative study.

The research suggested the accepted practice of allowing multiple professional entities to insert and manage PIVCs jeopardizes patient safety. They called for consistent approaches for all interdisciplinary professionals to follow. This suggests there is an opportunity to improve the current fragmented process to achieve positive outcomes with vascular access ownership of (i) assessment, (ii) insertion, (iii) care maintenance, and (iv) education. 

According to the US Centers for Disease Control and Prevention (CDC) in 2011, “Specialized teams have demonstrated unequivocal effectiveness in reducing infections, complications and cost of infusion therapy.”

Although there are studies reporting that a vascular access services team (VAST) positively impacts patients’ vascular access outcomes, there are no randomized controlled trials to support or refute the role of the VAST. A Cochrane systematic review on VAST describes a lack of high quality research on teams.

The Cochrane review defines these groups as any of the following; infusion teams, intravenous teams, individual specialists (nurse, doctor, respiratory therapist, radiological technologist, nurse practitioner, and physician assistant) who have knowledge and skills, through formal training, and who frequently perform insertion or manage VADs.

The Infusion Nurses Society standards of practice present practice criteria for an infusion team and include benchmarks for peripheral and central catheters which include: first time insertion success; daily assessments; decrease in catheter related blood stream infections (CRBSI); increase in patient satisfaction; data collection for reporting quality outcomes; and impact on patient safety.

The purpose and function of a VAST or trained individual may include the initial assessment, insertion and management of PIVCs, midlines, PICCs, arterial catheters, external and/or internal jugular, femoral, and subclavian placed catheters.

Teams and individual specialist functions will vary and may exclude the insertion and maintenance of some of the devices and associated activities listed above. Other functions embraced by these specialists may include patient access for difficult blood draws, use of ultrasound guidance for any or all of the functions, dressing changes for central catheters, daily evaluation of catheter necessity, removal of unnecessary catheters, and monitoring of dressing and insertion site for complication identification. Additionally, they provide a professional point of care for education and resource of VAD queries for device maintenance and management of complications. However strong the evidence for specialized teams, professional application of empirical guidelines for teams within the acute care setting is limited.

Whether through lack of awareness of guidelines and recommendations, changing administrative priorities or perceived economic constraints, the hospital adoption and support of VAST has been erratic. Similar to specific services where a cardiologist is required for specific cardiac problem to provide the best evidence-based care, it is logical that seeking the services of a trained vascular access clinician to initiate and maintain the most appropriate intravenous device, is a worthy mandate. Given the growing complexity in patient needs, a unique specialist discipline, namely the VAST. is surely needed to provide for patient needs. Specialty teams are also seen as models that not only improve patient safety and outcomes but also can serve as a platform for clinical training of junior residents, medical students, and nursing clinicians. The evidence to date is suggestive that the highest achieving system of initiating and delivering treatment to patients in acute care is inexplicably tied to a purpose-driven group of skilled individuals and the processes that guide their practices.

Evidence supports the value of a specialized infusion team for improved success with access, reduced insertion attempts, and reduced complications associated with intravenous or arterial device insertion. According to da Silva in 2010, use of a specialized team increased first attempt success with only 16% of attempts resulting in more than 1 attempt.

Teams of specialized individuals performing insertion of PIVCs report increased first-time insertion success.

Complications associated with VADs relate to the skill and knowledge of the operator for insertion

and for post-insertion complications related to maintenance by clinicians and patient specific risk factors.

Specialized education has led to infection prevention practices that reduce complications.

Advanced practice nurses and those teams receiving specialized training to perform insertions of all CVADs that work in collaboration with medical providers offer valuable contributions to the clinical care by performing insertions with low incidence of complications.

Consistent across all VADs, peripheral and central, teams historically represented the lowest levels of device-related complications.

Adoption of a team approach for care and maintenance has resulted in reduction of CVAD-associated infections.

Adverse vascular events are largely avoidable through specific practices of assessment and selection of the vascular access device with the lowest infection risk for the patient and their treatment (

). Improving selection of the best device and inserter skill reduces unnecessary central venous catheter insertions.

These practices are evidenced in a variety of specific models, recommendations, and guidelines such as the Society of Healthcare Epidemiology of America (SHEA),

Infusion Nurses Society (INS) Standards of Practice,

European Society for Parenteral and Enteral Nutrition (ESPEN),

World Congress of Vascular Access (WoCoVA) consensus,

Evidence-based Guidelines for Preventing Healthcare-associated Infections (EPIC),

and National Institute for Clinical Excellence (NICE)

all recommend a focus on the necessity of specialized training for inserters and those managing VADs that integrate infection prevention and practices that avoid complications. Despite these recommendations, many insertion attempts of VADs are performed by clinical professionals with little to no formalized education or current training on insertion or the means to prevent complications with emphasis placed on the central line bundle and other practices that include device assessment for risk reduction as a key component.

Vascular access catheter insertion is accepted as an invasive clinical procedure that exposes patients to iatrogenic risks such as procedural pain, bruising, bleeding, vessel depletion, and inadvertent anatomical injury of adjacent structure, infection, and in extreme cases death.

When intravenous, peripheral, or central catheters are required, patients may undergo multiple attempts to successfully insert these devices. Moreover, initial device insertion can be associated with procedural complexity that involves repeated attempts following insertion failures leading to increased patient risk of complications. 

Such complications associated with VADs are increased as the number of attempts and time during the insertion procedure increases.

Insertion of peripheral catheters by a variety of skilled and unskilled clinicians result in failure rates of 1.9 vs 2.9 insertions

For these reasons alone hospitals with VASTs reported higher insertion success rates and greater patient satisfaction.

Results of unsuccessful peripheral catheter attempts lead to vein depletion,

bruising and pain at the insertion sites,

and multiple punctures of the skin predisposing microorganism entry into the bloodstream. 

Consistent with the VHP model for selecting the right device, right site, inserted by the right clinician (people) at the right time, the clinician performing the insertion must have training, qualification, and competence to perform the procedure in a safe manner.

Education and training of staff integrates technology that facilitates increased success. Ultrasound and visualization technology knowledge and training aid inserters in gaining access on the first pass and minimize number of attempts and complications associated with multiple attempts and traumatic insertions.

Complications increase in number when there is difficulty with insertion. Currently, most patients will experience insertion failure and post-insertion failure prior to definitive device placement during their course of treatment. In research by Eisen and associates (2006), there was a 54% increase in complications when 2 or more puncture attempts are performed.

Inserters with experience of fewer than 50 CVAD procedures have greater than 50% risk of a complication occurring and more difficulty achieving successful insertions.

The use of specialist teams has demonstrated more positive clinical outcomes for patients including greater first attempt success, reduced CLABSIs, and subsequent economic advantages.

Insertion of VADs is not without risk, but risk is also associated with management of these devices that comprises the largest time component of each patient’s treatment process. Management of VADs requires the performance of regular assessment of device function, insertion site, securement, dressing adherence, and observation for signs of other complications. Of greatest concern is catheter-associated bloodstream infection (CABSI), as in the case of peripheral or central venous catheters, and specifically central line-associated bloodstream infection (CLABSI).

In a study of maintenance bundles, CLABSI rates fell from a peak of 5.2/1000 catheter days to zero infections for 24 months by using a bundle incorporating antimicrobial sponge dressing, chlorhexidine body wash, and daily device assessment by a specialist nurse.

Results of a cross-functional team demonstrated effectiveness in post-insertional care with statistically significant CLABSI reduction with major economic impact.

Evidence has demonstrated that education and training for insertion and maintenance of VADs, which includes criteria for educational content, simulation of practice and supervision, results in improved staff compliance with safe practices.

Recommendations for education in the clinical setting are to provide consistent and varied staff education on infection prevention, best practices and consequences of poor technique.

Clinicians performing consistent insertions and maintaining current education with evidence-based practices are better equipped to provide safe patient care.

Application of evidence through education, while promoting peer to peer engagement, lead to high performance and consistency in safety practices.

Effective device and site selection necessitates a heightened awareness of infection prevention guidelines that aid in site selection and insertion and the ability to choose the number of lumens necessary to complete treatment to minimize risk.

A higher risk of infection and other complications is associated with CVAD insertion when performed by unskilled, inexperienced, or unqualified inserters.

Therefore, integration of education, simulation practice, ultrasound training, and knowledge of complication management for CVAD insertions are part of the procedural competency necessary for those clinicians inserting or managing VADs.

Patient-focused safety initiatives should apply evidence of improved outcomes such as those represented in establishing and maintaining effective vascular access teams. Providing a consistent VAD assessment, insertion, and management service to patients in the pursuit of risk minimization involves healthcare personnel who have received special training. VAST contribute to infection prevention efforts to reduce CLABSI, CRBSI, and CABSI. Patients indicate the inadequate skill level of those performing these types of procedures is a source of great dissatisfaction, while use of technology and increased skills of the VAST promotes higher satisfaction.

These occurrences were exposed in the qualitative study of patient and staff experience indicating a need for vascular access specialist as a quality initiative.

Device and vein selection and insertion processes, qualified inserters, effective management and evaluation of practices, clinical outcomes are all improved as reflected in the elimination or reduction of complications, prolonged dwell times, reduced length of stay and improvements in patient satisfaction.

Teams have the potential to effect significant improvements through both insertion and post-insertion care of patients. Providing dependable vascular access assessment, insertion techniques, and post-insertion care and management is a necessary patient requirement to support modern healthcare treatment plans, patient safety, and promote economic savings through efficiency of insertions.

The value of specialized teams for insertion and management of vascular access has been demonstrated through numerous publications in a variety of research designs. Although there are currently no randomized controlled clinical trials that support the benefits of teams, the recommendation of the CDC and others continues for specialists as a method to reduce complications and infection associated with vascular access devices. Additionally, standards for infusion therapy call for teams for CVAD insertion, maintenance, and removal to promote patient safety and better outcomes. The discussion and research underscore the potential advantages of VAST for assessment, insertion, management, complications reduction, and staff education. Supported by the concepts of vessel health and preservation, the application of specialty teams in every hospital for insertion and management of vascular access devices could significantly contribute to the pursuit of making VADs complications history.

Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BC, is the chief executive officer at PICC Excellence, Inc., an associate researcher for the Alliance for Vascular Access Teaching and Research (AVATAR) Group, and an adjunct associate professor at Griffith University in Brisbane, Australia.

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The discussion and research underscore the potential advantages of vascular access services teams (VASTs) for assessment, insertion, management, complications reduction, and staff education.

Establishing Vascular Access Teams for Patient Safety

Construction is a dirty business. All sorts of dust, debris, concrete, and wiring will be part of any expansion. When a hospital is adding onto an existing department or is making changes within that department, it is often referred to as a phased build. When engaging in a phased build, hospital administrators, infection preventionists, and other staff must deal with the threat that the construction could spread contaminates into adjacent areas. Early discussion and risk assessment associated with the type of construction, scope of construction, and length of construction is key to minimizing the potential impact.Do not lose sight of the fact that many patients and families spend time adjacent to these areas.

Construction in healthcare happens for a reason. Most likely it is driven by growth, regulations, or improving the patient experience. Hospital administration should identify key stakeholders and subject matter experts who have relevant knowledge of the expansion being considered. The most important area of concentration is keeping in mind that the goal is best outcomes for patients. If best patient outcomes are the deciding factor, decision making becomes much easier. For example, it may be necessary to change materials flow near a construction zone in order to keep consistent separation between clean and dirty materials. If patient flow or experience is impacted by the need for new materials or pathways, the safety and experience of the patient should be the most influential factor in decision making. 

Renovation or construction that happens in preexisting spaces or occupied areas have very different sets of challenges than the building of new facilities. The current phase of the construction and the assessment of risk will help determine necessary intervention. Demolition, for example, in the existing or adjacent areas creates dust and debris. It also creates a need to remove construction debris from the site to an appropriate disposal location. In some cases, thousands of pounds of concrete, dirt, and other contaminates will need to be moved from point A to point B. During construction planning, ensure that the commingling of pathways of construction materials is minimized with clean pathways and patient transport.

After demolition, the project moves into an active construction phase. Have you ever sanded or seen someone sanding drywall? After a short time, the person looks like they have been covered in baby powder. Hopefully the individual is wearing a mask that keeps he or she from inhaling the dust. Imagine the amount of drywall dust that is produced in a large expansion. All of that fine particulate has to go somewhere. What happens to all that dust in an adjacent construction zone? These are just some of the considerations the group-and especially infection preventionists-should address in order to contain possible contaminates that become more prevalent during construction in pre-existing departments.

Construction contaminates follow a similar pathway as the chain of infection. The illustration of a chain is often used to show how illness can be transmitted between individuals. Most importantly, the illustration also indicates that if a link of this chain is removed, then the cycle of infection is broken. Imagine infection prevention during construction and breaking the chain. If the “EXIT” link is properly managed, it can minimize or prevent issues downstream. Concentration on the first 3 links in the chain is important; these 3 links are the most actionable when dealing with infection control risk during construction.

Agents, more precisely infectious agents in a construction zone, are not difficult to find. Spores, bacteria, and molds are readily found in air and soil. Many of these common contaminants are harmless to most people with healthy immune systems. Focus on the patient. Patients in healthcare are diverse and their healthcare needs vary drastically. Patients may have suppressed immune systems, respiratory issues, or other comorbidities that could place them in a higher risk category for getting an infection than that of a healthy individual. Hospitals manage the risk of transmission on a daily basis as part of their current infection control and cleaning protocols. Daily hospital practices are focused on the current state of business. When a construction project is added to the mix, special attention needs to be taken to identify the risk of possibly increasing the presence of these infectious agents.

In the infection control chain, a reservoir is an object or person that agents can attach to and live on. During a construction project, there are limitless reservoirs moving in and out of the construction zone with great frequency. Retained agents on individuals clothing, wheels on carts, and work boots all need to be evaluated. These reservoirs are an essential part of the construction business and cannot simply be removed. The goal in this situation is mitigating the risk of spread by addressing the next link in the chain, the exit.

The exit link in the infection control chain cannot be overemphasized as a key area of attention. If all construction projects could be contained in an airtight bubble and all reservoirs never left the bubble, contamination would be eliminated. In reality we all know that this scenario is impossible. Assessing the exit link is critical because it is the link of infection prevention that during construction projects is most actionable. Countless steps could be taken to eliminate exit risk. However, there also needs to be an awareness that the institution needs to remain operational. Restricting material flow patterns is a potential risk management strategy. Design and communicate to key individuals pathways that prevent commingling of construction reservoirs with clean and patient pathways. Consider designating an elevator for construction use while the highest risk materials are being transported in and out of the facility. When addressing foot traffic, asses the benefit of clean mats at entrance and exit points. Once heavy construction and demolition have been completed, removable shoe or boot covers are another means to limit contaminants from leaving the construction zone. Ensure collaboration between infection preventionist and environmental services to assess the need for additional floor cleaning and surface cleaning during the extent of the project. When appropriate, separate construction zones with sealed walls in order to eliminate airborne contaminates from exiting the zones. If appropriate use high-efficiency particulate air (HEPA) filtration in order to reduce airborne particulates in the construction zone.

Many of these considerations also bring temporary challenges to daily operations. When pathways are closed and elevators are dedicated, it impacts staff and the patient experience. Ensure key stakeholders that these changes are important for patient and staff safety. The inconvenience is only temporary and the need for containment is crucial.

Construction is a dirty business, but also a doorway to potential change. During the construction planning, infection preventionists, hospital administrators, and others on the frontlines of infection control should take a moment to consider the future state of the new space. Infection prevention is an ever-changing world. Careful design of the new space can eliminate need for construction in the future and improve the facility’s ability to carry out effective infection control in the long run. Considerations during planning could include adequate storage and the availability of personal protective equipment. Ensure isolation signs are placed at focus points. Ensure that hand hygiene can be performed easily and is readily accessible. What might seem like a small consideration during the planning of a new space might have the most significant impact to operations and patient safety for years to come.

As healthcare providers, the goal should be zero patient harm. Timeouts, patient verification, and medication reconciliation are some of the safety standards clinicians exercise every day. Ensure the individuals on the construction team, especially those who are not clinicians, have a reverence and acknowledgment that lives are potentially at risk and that they are making the difference. 

Christopher Whiting is the sterile processing manager at Nationwide Children's Hospital in Columbus, Ohio. He has been in the field of sterile processing for 22 years. Whiting graduated from Bowling Green State University with a bachelors in English and Sociology. He is a CRCST and vice president of the Mid-Ohio Central Service Professionals chapter of the International Association of Healthcare Central Service Materiel Management (IAHCSMM). 

Renovation or construction that happens in preexisting spaces or occupied areas have very different sets of challenges than the building of new facilities.

Breaking the Chain: How to Better Contain Infection Risk During Hospital Construction

It’s a matter of demographics, say the authors of an article in press in the Journal of Post-Acute and Long-Term Care Medicine.1 COVID-19 will disproportionately hit nursing homes and other long-term care facilities because the disease is particularly lethal to the elderly. With that in mind, investigators with Brown University and the Veterans Administration are putting out a call against the blame game. Under a subtitle in the article that is, in fact, labeled, “The Blame Game,” they write: “In recent years, negative outcomes in nursing homes during disaster situations have led the media, public health officials, and politicians to find fault with nursing home providers.” Investigators cite the case in which 4 nursing home workers were charged with criminal homicide in Florida during Hurricane Irma. Without commenting on the particulars of that case, the “historical reality is chilling” given that the epicenter of COVID-19 in the United States is the Life Care Center in Kirkland, Washington where, as of this writing, COVID-19 was found in 81 residents, 34 staff members, and 14 visitors; and 23 people died. “Quite clearly, mortality within long-term care environments related to COVID-19 will be significantly higher than among the general population as a function of resident advanced age and comorbidity rather than substandard care,” the article states. “Some understanding of this fact will certainly be welcomed by the long-term care industry, who are often responsible for delivering difficult care under suboptimal circumstances.” The fatality rate in China for those 70 to 79 is estimated at 8%, and for patients over 80, that shoots up to 14%. “Even as the overall case fatality rate drops, the risk of death among older adults may be 10-fold higher than for younger individuals,” the article states. Mortality rates also increase with the presence of heart or chronic respiratory disease, which are common in long-term care facilities. Rates of heart disease exceed 30% and, for chronic obstructive pulmonary disease, it exceeds 20% in long-term care facilities, say investigators. “Further, extreme functional impairment within long-term care facilities makes close contact between health care workers and residents inevitable,” the article states. “Additionally, cognitive impairment among residents may make contact precautions and isolation a practical impossibility.” Workers should wear gowns, gloves, facemask, and eye protection, but…  “This may be challenging in the nursing home environment, where supplies of these items may be limited and are prioritized for acute care hospitals,” the article states. “In long-term care settings, few of which have negative pressure (airborne isolation) rooms, simple measures like pulling room-dividing curtains and closing doors are helpful.” Even the admonishment that workers with symptoms need to stay home can be problematic, as most of the workers live paycheck to paycheck and long-term care facilities are often understaffed. Workers are used to being pressured to work even when sick. “Providing a work environment that allows healthcare workers to call out without repercussion will be critically important,” the study states. Whether to admit someone who has been diagnosed with COVID-19 will be another concern. “Long-term care facilities are a key component of our healthcare system, and we can anticipate significant pressure to receive discharged hospitalized patients for convalescence or to accommodate sicker patients arriving from the community,” the article states. “We do not yet know how long individuals shed transmissible levels of virus, whether older individuals shed virus longer, nor whether cohorting confirmed cases can reduce risk of spread within a facility or contributes to disease severity among those cohorted.”  -------------------------------- 

Q&A: A Conversation with David Dosa, MD, MPH

 reached out to the study’s corresponding author, David Dosa, MD, MPH, an associate professor of medicine and health service, policy & practice at Brown University’s School of Public Health. 

 Your article seems to be a preemptive attempt to dissuade experts and the public for blaming the spread of COVID-19 on long-term care facilities. Is that a fair assessment? 

 I have worked in the area of disaster preparedness and nursing homes since 2003. The universal theme throughout this time is that nursing homes are often ignored by public health officials and at times unfairly held to standards in the post-disaster dialogue (eg, Monday morning quarterbacking) that they were never financially equipped or staffed to handle. Bottom line-nursing homes are not hospitals, yet they are asked to take care of some of our sickest patients. The point of the article was to raise awareness that there are a lot of unanswered questions that are not necessarily first and foremost on the minds of public health officials and politicians. As you have seen in the Washington state case, they really will need to be a key focus in this epidemic. 

 You touch on many aspects of what makes dealing with COVID-19 especially difficult in long-term care facilities. Your point, as far as I can tell, is that LTCs are the most vulnerable institutions and yet they have the least to work with? True? 

 Nursing homes do have some experience with outbreak situations such as influenza. Nevertheless, they are not set up with negative pressure rooms and staff members are not trained in most circumstances to gown up in full protective gear. In fact, most nursing home residents live in rooms with more than one resident, making infection control extremely difficult. Coupled with the intense functional needs that most nursing home residents require, this makes infection control challenging under optimal circumstances. 

 Immediate recognition that infection control in the nursing home remains a challenging situation to address. Help from infection control professionals in preparing these facilities to address the COVID-19 crisis. Some additional financial resources from federal and state governments to allow nursing homes to temporarily increase their staffing levels, acquire the necessary equipment, and allow for enhanced screening of staff, vendors, and visitors (if they are allowed) would also be important. 

 It starts with making the public aware, correct? 

 The public really does need to be aware of why some of the draconian policies related to visitation are going into effect in this environment. The experience in Washington state and the newly announced case in New Orleans makes this all the more apparent. 

 One of the key factors in preventing outbreaks within nursing homes will be paid sick leave for employees-often those with the most contact with patients (LPNs, aides, etc) work multiple jobs at hourly wages. If they don’t work, they don’t eat and that prompts many to come to work even when they don’t feel well. Nursing homes really do need to institute plans to check all who enter for symptoms and send those who are sick home. Paid leave would help in this situation.  

Dosa D, Jump RLP, LaPlante K, Gravenstein S. Long-term care facilities and the coronavirus epidemic: practical guidelines for a population at highest risk. 

. 2020;Mar 13. pii: S1525-8610(20)30249-8. doi: 10.1016/j.jamda.2020.03.004. [Epub ahead of print].

The media, public health officials, and politicians are accused of being too quick to find fault with nursing home providers.

Long-Term Care Facilities Particularly Vulnerable to COVID-19 (and Criticism)

Despite nursing homes becoming a nidus of multi-drug resistant organisms (MDROs), the regulations for staffing infection preventionists (IPs) at nursing homes are far too lax. Nursing homes should have a full-time IP. Presently the regulations only specify a part-time IP without a specific required time commitment. In view of the large number of nursing home residents and the high drug-resistant carriage rate, a full-time position is certainly needed.

That’s especially true these days, as COVID-19 hits nursing homes with particularly devastating results. At the now-infamous Life Care Center, a 130-resident nursing home facility in King County, Washington, COVID-19 infected 81 residents, 34 staff and 14 visitors, causing 23 deaths (22 of them residents).

More recent updates place the total deaths at 35; 34 of whom were residents. As of March 23, 127 of the 15,000 nursing homes in the United States had at least 1 resident who tested positive for COVID-19.

Mortality rates also increase with the presence of heart or chronic respiratory diseases, which are common in nursing homes and other long-term care facilities. Rates of chronic obstructive pulmonary disease are greater than 20%, and for heart disease they are greater than 30% in long-term care facilities. 

So, expect mortality from COVID-19 to be significantly higher at nursing homes and other long-term care environments than among the general population just as a function of advanced age and comorbidities of the residents. In China, the case fatality rate (CFR) is estimated to be 8.0% for those 70 to 79 years of age, and for patients over 80, that shoots up to 14.8%.

Even as the CFR drops with improved treatment, it is expected that those over the age of 80 will have a 10 times higher fatality rate than younger patients.

Many nursing homes around the nation have suspended all visitations, which hopefully will increase the awareness of the importance of controlling the microbiome in nursing homes. Most hospitals routinely screen patients admitted from nursing homes for MDROs, but nursing homes seldom engage in similar action.

Nurse staffing in nursing homes is also all too often inadequate, although state requirements may vary. The federal government relies on the requirement to have “sufficient nursing staff.” The definition of “sufficient” is largely in the eyes of the facility.

In addition to low staffing, salaries for nursing home nurses are lower than they are at hospitals. According to payscale.com, the average RN and certified nursing assistant are paid $28 and $12 per hour, respectively, as those in hospitals are paid $29 and $13 per hour. Even at these salaries, coverage of living expenses can be difficult.

In terms of quality of care, none of the US Centers for Disease Control and Prevention’s 5 most “urgent threats”

are mandated to be reported on a national basis by nursing homes. The only nationally reported data on infectious disease which can be found on Nursing Home Compare are for urinary tract infection. State requirements vary widely. Nursing homes need to have a comprehensive mandatorily reported national tracking system for infectious disease.

Even before the COVID-19 virus refocused the nation’s attention on nursing homes, there were severe deficiencies in infection control. A recent study in California found that over 50% of nursing home residents harbor MDROs.

Of course, extrapolating this data to the entire nation needs to be done with caution, but California has one of the lowest rates of antibiotic usage in the nation.

Some states in Appalachia, such as my home state of Kentucky, have over twice the utilization. At the very least, this study raises grave concerns.

Required antibiotic stewardship programs are all too often ineffective. The CDC estimates that up to 75% of antibiotics in nursing homes are not prescribed correctly.

One study found that 42% of the residents in nursing homes are carriers for methicillin-resistant 

(MRSA) and 34% carry extended-spectrum Î²-lactamase-producing organisms.

Both of these organisms are defined as “serious threats” by the CDC. CMS tolerates a medication error rate of 1 in 20 prescriptions.

There are few requirements for antibiotic prescription oversight. The CDC recommends antibiotics administered for sepsis be rechecked by a professional within 48 to 72 hours after initiation. This standard should also be applied for all antibiotics given in nursing homes. A common failing is the unnecessary continuation of antibiotics in newly admitted residents, since a facility physician visit is not required for up to 30 days post admission and if requested, it is considered timely if it occurs within 10 days.

In response to this threat, the US Centers for Medicare & Medicaid Services (CMS), in collaboration with the CDC, will be initiating targeted infection control inspections with streamlined checklists. During this time standard inspections of nursing homes will be suspended. However, the current CMS suspension of standard inspections indicates a temporary shifting of resources and unless a permanent commitment of new resources is made, there may well be a rapid return to the status quo.

The CDC has also attempted to strengthen regulations which give little if any firm guidance. The CDC has developed a program for nursing home infection prevention referred to as “enhanced barrier precautions.” Although the name implies strict infection control procedures, it may actually be recommending far too little to control the frequent occurrence of dangerous contagions in nursing homes. 

The premise behind the protection of healthcare workers and residents with enhanced barrier precautions is that some resident encounters have a higher risk of transmission of pathogens than others. And that contact precautions should be reserved for those encounters with the highest risk, thus, helping to preserve the patient’s dignity. However, recommendations need to be effective, since no nursing home resident wishes to preserve dignity by infecting visiting grandchildren with a dangerous contagion. 

Three of the organisms which are targeted for control with enhanced barrier precautions are contained on the CDC’s list of “urgent threats.” MRSA, another common nursing home pathogen, is also targeted and is on the CDC’s list of “severe threats.”

There are 2 concerns. The first is that although lower risk encounters carry a relatively low risk of transmission, some encounters, such as passing meds, occur so frequenty that the risk to the healthcare worker over time can be high. For example: The passing of meds to a MRSA carrier is defined as a low-risk activity. Each encounter was found by Roghman, et al., to contaminate healthcare workers’ gowns and gloves with MRSA 8% and 16% of the time, respectively.

The study found a 25% MRSA carrier rate in nursing home residents and if one assumes a healthcare worker passes meds to 25 patients 3 times a day, they would be expected to contaminate their clothes 11 times a week.

Another study by Blanco, et al., evaluated the risk of contamination with gram negative bacillus.

Using the same methodology, it can be predicted that the passing of meds would result in the contamination of a healthcare worker’s clothes once a week.

The second is that enhanced barrier precautions do not restrict the movements of a carrier within a facility, which is problematic. The CDC notes that environmental colonization with MDROs can last longer than 6 months.

In the case of MRSA, one study has found colonized patients contaminated the environment more frequently than those with an active infection.

MRSA carrier contamination of the environment can occur very rapidly with 35% of carriers contaminating their environment within 33 hours

and the contamination may last as long as 2.33 to 8.35 years.

We need to start fostering an optimal patient microbiome, but the United States does not even adequately screen for MDROs. 

, for example, is a major cause of post-operative infections. The WHO recommends that in affluent countries, all patients undergoing surgery be screened and decolonized for 

These pathogens are relentless, they are evolutionarily programed to win, and they are currently doing just that.

Infection Control Today, May 2020 (Vol. 24 No. 4)

May 2020 Bug of the Month

Establishing Vascular Access Teams for Patient Safety

Breaking the Chain: How to Better Contain Infection Risk During Hospital Construction

Long-Term Care Facilities Particularly Vulnerable to COVID-19 (and Criticism)

When COVID-19 Knocks on Nursing Homes’ Doors, Systemic Problems Welcome It

When It Comes to Fighting Covid-19, Some Problems Can’t Be Masked

Searching for the Missing Link (Nurse)

A Conversation With Judd Hollander, MD: How Telehealth Can Address the COVID-19 Outbreak