Implementing Effective Infection Control Programs in Nursing Homes
Date: March 1, 2020 | By: Dr. Christopher Morgan, MD, FAAP, MACP Chief Medical Director, AMS Infection Prevention Partners
[March 1, 2020] All continents now have an outbreak of the Coronavirus, except Antarctica. International stock markets have wiped away $6 trillion in value due to the world threat of a pandemic. Here in the United States, the Centers for Disease Control and Prevention (CDC) is preparing for the pending outbreak, requesting $2.5 billion to start. The American Health Care Association has issued alerts to their nursing home members--all as our first two cases have been identified in a Washington State facility this past weekend. While everyone needs to be diligent and cautious, it is even more important for our at-risk seniors and those that care for them to be on high alert.
Seniors at Higher Risk
The Coronavirus family of viruses is not new. Certain strains of Coronavirus are ubiquitous in the human population and cause 5 to 10% of acute respiratory tract infections in children and adults that can lead to severe complications including death in those who are more susceptible. The emergence of this particular strain of Coronavirus from China is of the same family but, to our knowledge, has never been seen in the human population. This means that we have no inherent immunity that would have resulted from prior exposure like we do with other strains of this virus family. The virus infects the lungs and results in a destruction of lung tissue called viral pneumonitis. Similar to other viral respiratory infections, the destruction of the lung tissue is a significant risk factor for secondary bacterial pneumonia which has a much higher mortality rate. As we have seen in the media a vast majority of deaths associated with this infection have been elderly patients who have multiple other medical problems. As we age, our immune system decreases in effectiveness. When we factor in other medical problems that are more prevalent in the elderly and that affect our immune system as well, including diabetes, heart disease, chronic lung disease, cancers, etc., our aging population is at high risk for complications and increased mortality from any infection, particularly this Novel Coronavirus.
Novel Coronavirus Cannot Be Stopped
In the U.S. this week, there have been confirmed transmission reports of the Coronavirus in communities between people who have no history of travel or contact with those that have known infections. Additionally, an emerging aspect seems to be people who are contagious but do not exhibit any symptoms. In other affected areas of the world, there have been documented cases of people who have positive test results--but never experience symptoms. The result is a virus that is capable of being transmitted between people who are not sick and who continue to carry on in their daily lives. This situation is the main reason the Novel Coronavirus will never be contained or eliminated. This particular strain of Coronavirus is unfortunately here to stay and will become endemic in the world. Treatment and vaccination options are months if not years away.
Nursing homes come in all sizes, but typically our 16,000 U.S. nursing homes range in occupancy of 60-150 beds with most residents sharing a room. It requires 30-75 nursing home staff to support these residents. In addition to this community population, resident's friends and families make visits from near and far. With support personnel and family members also entering our airports, using public transportation, traveling afar, participating in school and religious activities-- it is just a matter of time until more outbreaks occur.
To minimize a nursing home’s risk, there are simple precautions they can take, which are vital to the safety of their residents.
“Unfortunately, nursing homes tend to be more reactive rather than proactive. I’ve seen too many times when nursing homes do not prepare for outbreaks. If we want to minimize Coronavirus or any outbreak, we need to change this behavior,” says Heather Hutson, RN IP-BC, an Infection Preventionist for AMS. She suggests some simple actions nursing homes should immediately perform:
Check your inventory of Personal Protective Equipment (PPE) and supplies (especially gloves, gowns, masks and eye protection) and order accordingly
Train front-line staff on how to appropriately use PPE, when to use it, and where to find it
Retrain and remind all staff and visitors on proper hygiene and when to stay home
Heather also suggests posting signs at all entry doors reminding visitors to take precautions such as washing hands and safe techniques for coughing and sneezing. Remind visitors that if they are not feeling well, do not enter the building. And, let them know if they have traveled to states or foreign countries where the virus is spreading, they shouldn’t visit the facility for 14 days, which appears to be the accepted incubation period for the virus.
What Should A Nursing Home’s Infection Preventionist Be Doing?
The Centers for Medicare & Medicaid Services (CMS) has recently mandated long-term facilities adopt an antimicrobial stewardship program that addresses many aspects of infection control and reduction in the use of inappropriate antibiotics used mainly in respiratory infections.
Our nursing homes now have a certified Infection Preventionist whose responsibility includes generating facility-wide programs and protocols that reduce the incidence of infection outbreaks. Facilities have chosen various paths to comply with these new requirements; I recommend facilities utilize outside professionals in the area of infection control. Nursing home care givers are overworked and understaffed; I feel it is a somewhat risky to just rely on them to also be the nursing home’s all too important Infection Preventionist. Get support by professionals that just focus on infection control.
One directive of the new CMS antimicrobial stewardship program suggests facilities have an infection surveillance program. With the emergence of the new Novel Coronavirus, infection surveillance becomes even more important. Newer Polymerase Chain Reaction (PCR) respiratory testing is available that can be used to support surveillance programs and has been shown to not only decrease antibiotic use but also decrease BOTH viral and bacterial outbreaks in nursing homes by periodic and symptomatic testing (PCR testing for Coronavirus is available today). The results are usually received within 24 hours so the nursing home can implement isolation processes/protocols if necessary. The CDC states that nursing home residents have 3 to 4 respiratory tract infections per year. By identifying the virus/bacteria, facilities can address the results immediately and appropriately, before further contamination occurs within both our seniors and care givers.
Stay Alert And Stay Ahead
While this Coronavirus outbreak is very worrisome, it is not impossible for us to overcome. We will prevail through the use of smart tactics and diligence. Protecting our vulnerable seniors is one of our nation’s top priorities. Washing hands, staying home if you are not feeling well, and covering your mouth are all still highly effective today as they always have been. Train and retrain nursing home staff on infection processes and procedures, ensure nursing home supplies are in place and make sure your nursing home has a proactive infection preventionist and respiratory testing program in place. Facilities that follow these recommendations will minimize their Coronavirus risks and if an outbreak does occur, they will quickly be able to isolate it.
About Dr. Christopher Morgan:
Dr. Morgan is a Partner at AMS which offers all-inclusive Antimicrobial Stewardship Programs to long term care communities. AMS provides skilled nursing facilities with certified infection preventionists as well as PCR testing, including for the Novel Coronavirus.
Dr. Morgan has been practicing internal medicine and pediatrics in a group practice associated with Baptist Health Stuttgart Medical Center in Arkansas for the past 16 years where he has served as Chief of Staff. Board certified for Internal Medicine and Pediatrics, his practice consists of both inpatient and outpatient adult and pediatric patients. Dr. Morgan also serves as a regional hospice director for Baptist Health systems. Additionally, for the past 14 years, Dr. Morgan has served as the medical director for Chambers Nursing Home and Rehabilitation Center in Carlisle Arkansas. This facility consists of 90 beds and provides care for both long term care patients and complex patients with rehabilitation needs.
Dr. Morgan received his BA in Biology from Hendrix College in Arkansas and received his MD degree from the University of Arkansas for Medical Sciences where he graduated with honors. He completed his Internal Medicine/Pediatrics residency at the University of Arkansas for Medical Sciences, including training at Arkansas Children’s Hospital and the McClellan VA Medical Center where he served as chief resident his last year. Dr. Morgan maintains privileges at Arkansas Children’s Hospital, Baptist Medical Center Stuttgart, and Baptist Medical Center Little Rock and sits on the Arkansas Antimicrobial Committee of the Arkansas Department of Health.
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