A proposed rule by the CMS calls for a sweeping upgrade of infection control in nursing homes, solidifying the role with a new title and making it a higher priority through annual risk assessments and much-needed antibiotic stewardship requirements.
Specifically, the draft CMS regulation would require long-term care settings to have an Infection Prevention and Control Program (IPCP) charged with “preventing, identifying, reporting, investigating, and controlling infections …for all residents, staff, volunteers, visitors, and other individuals” based upon a facility and resident assessment that is reviewed and updated annually. To spearhead this effort, the nursing home would designate an Infection Prevention and Control Officer (IPCO) with specialized training to have the “major responsibility” for the program.
“It is a very substantial revision — a needed change because it really formalizes the infection control program,” says Kirk Huslage, RN, BSN, MSPH, CIC, vice chair of the public policy committee of APIC, and an IP with the North Carolina Statewide Program for Infection Control and Epidemiology, UNC School of Medicine, Chapel Hill. “I was surprised that they put in a requirement for an infection preventionist essentially — the infection control officers. That’s a great step forward and something that is needed.”
Regarding the job title, CMS has been asked by at least one commenter to officially change it to Infection Preventionist, bringing it in sync with the official designation now widely used by APIC and others in the field.
“Infection Preventionist is the professional title for the expert who manages and coordinates the infection prevention and control program,” Deb Burdsall, MSN, RN-BC, CIC, of the University of Iowa College of Nursing, said in a submitted comment on the CMS proposed rule. “This title is frequently used in acute care [and is] recognized by professional infection prevention, control, and epidemiological societies. … A consistent job title across the entire healthcare continuum will help highlight the expanding role [of the IP.]” (Editor’s note: The comment period closes Sept. 14, 2015, at 11:59 PM ET. For more information or to post a comment go to http://1.usa.gov/1hIe6Du)
Though this may seem like a minor detail, IPs have been trying to clarify their role in healthcare and raise the profile of their programs. They have largely succeeded in acute care, though APIC had to call a press conference during the Ebola outbreak to emphasize that their prime mission is to prevent HAIs, which strike some 720,000 patients annually and kill some 75,000. Essentially, they warned if IPs were going to have to train healthcare workers about Ebola 24/7, patients were going to start acquiring other infections. The IP role in long-term care has been much more nebulous, but the infection control challenges are formidable in these settings. The new CMS emphasis on antibiotic stewardship and HAIs comes as part of the agency’s first major rewrite of long-term care conditions of participation since 1991. Annually, HAIs in nursing homes cause an estimated 150,000 hospitalizations, 388,000 deaths, and between $673 million and $2 billion dollars in additional healthcare costs, CMS stated.
“Everyone agrees that infections are a significant problem in nursing homes, but that is not necessarily because nursing homes are intrinsically bad places to be,” said Christopher Crnich, MD, PhD, hospital epidemiologist at William S. Middleton VA Hospital in Madison, WI. “You’ve got a fairly frail and susceptible population, so it is important to focus on how we can prevent infections. To their credit, I think a lot of nursing homes have been doing a lot of these things [proposed by CMS].”
Another new aspect of the CMS proposed rule is that the IPCO would have professional training in infection prevention.
“While nurses and other healthcare professionals may be likely candidates for the IPCO role, many of these professionals may have only received training in basic infection control practices in their core professional preparation for licensure,” CMS states. “The responsibility and necessary knowledge for an IPCP likely goes well beyond basic infection control training. Therefore, we propose to require that the IPCO be a healthcare professional with specialized training in infection prevention and control beyond their initial professional degree. Considering the diverse nature of the resident population and of the healthcare delivery model, the qualifications, training, and time needed by an IPCO at each facility would vary widely, thus we are not at this time proposing more specific requirements.”
The traditional perception has been that infection control is a part-time task, possibly a shared duty between workers in long-term care.
“We hold a course for long-term care and infection prevention every year in North Carolina and repeatedly, when we ask about jobs at the facility, [class members] will raise their hand for two or three different jobs,” says Huslage. “That really dilutes their ability to do any kind of substantial infection control interventions or surveillance. Dedicating the role is great because it is really going to give a little more gravitas to infection prevention in that setting and allow a more systems approach to infection prevention instead of this kind of piecemeal thing that has been going on.”
On first read it appears CMS is proposing a much more substantial job definition that will be someone’s “major responsibility.”
“We understand that infection control is often assigned to a nurse who may have other administrative or patient care responsibilities,” CMS states in the proposed rule. “We want to allow sufficient flexibility for facilities … but also ensure that an IPCO has the time and resources necessary to properly develop, implement, monitor and maintain the IPCP for the facility. Thus, we require that the IPCP be a major responsibility for the individual assigned as the facility’s IPCO.”
That certainly sounds like a win for resident safety, but the CMS appears to leave a loophole when it addresses this requirement in the estimated costs of the regulation. The CMS estimated a $284 million annual cost for enacting such infection provisions in long-term care settings nationally.
“The percentage of the RN FTE (full time equivalent position) that would be required at each facility will vary greatly,” CMS states. “We believe that each facility would have to determine the appropriate percentage based upon its facility assessment, especially its assessment of the acuity of its resident population. A facility with a generally healthy population of elderly individuals would likely require many fewer hours than a facility with a large percentage of subacute residents or residents that are on ventilators. For the purposes of determining an estimate, we believe that the average facility would designate an RN to be the IPCO and that individual would need to commit about 15% percent of a FTE to his or her responsibilities under the IPCP”
That is essentially six hours a week, says Huslage, who was drafting APIC’s formal comments to CMS when he spoke to Hospital Infection Control & Prevention. “I would certainly hope that there would be more than that — something like a 25% to 50% effort,” he says. “But I think they are allowing for some flexibility because there are nursing homes that are primarily convalescent care. The infection control job requirements are not as demanding [with] relatively healthy residents.”
That means risk assessments of infection control at the facility and the acuity of residents must be used to determine an appropriate level of hours for the IPCO. Likewise, the decision to put a resident under isolation measures involves a kind of risk-benefit analysis. Social interaction is an important component of long-term care, but residents with multiple indwelling devices or UTIs caused by MRSA, for example, might be candidates for isolation.
“It is challenging because it is a home-like environment - you cannot treat somebody like you would in a hospital.” Huslage says. “With contact precautions it is a kind of risk-based assessment, where you are looking at the resident, the complexity of care, the presence of line devices and a lot of other things in making an assessment of the transmissibility of that patient. We can make that patient-centered choice about not only what does their case require, but what is their risk to other people.”
The CMS proposed rule would require stewardship programs that include antibiotic-use protocols and a system for monitoring drug administration in long term care.
“Nursing homes are the next frontier where new antibiotic-resistant organisms may emerge and flourish,” the CMS stated. “Organisms such as Clostridium difficile and MRSA are known concerns. Nursing homes need to have the tools to participate in surveillance, learn and use infection control and containment practices, and adopt a proactive approach to preventing spread while being good stewards of antibiotics to preserve effectiveness of the agents we have today.”
There is compelling evidence now that antibiotic resistance is a problem that must be addressed across the healthcare continuum, says Crnich. Writing comments for the Society for Healthcare Epidemiology of America (SHEA), Crnich said the antibiotic stewardship requirements may take some out-of-the-box thinking for nursing homes, who typically don’t have an infectious disease physician or other antibiotic experts on staff.
“For example, making better decisions about when to take a urine culture,” Crnich says. “If the nursing home is doing a better job of testing people who have a high probability of infection and avoiding testing people with a low probability of having infections actually that can lead to a significant reduction in antibiotic use.”
In the absence of such stewardship strategies, some long-term care facilities are pouring on the antibiotics. “Some studies suggest that individuals who stay at a skilled nursing facility for six months have about a 60% to 75% chance of being exposed to at least one antibiotic,” he says. “[There are reports of residents] having a dozen antibiotic courses in a single year, which is an extraordinary amount of antibiotic pressure.”
While adding to the general negative trends of selecting out resistant bugs and losing drug efficacy, unnecessary antibiotic use is bad medicine period. Antibiotic use is one of the major causes of adverse drug events in residents, and can contribute to colonization with resistant bacteria that may eventually become a clinical infection. By wiping out commensal gut flora, a course of antibiotics can clear the way for C. difficile to set up in the patient’s gut.
“It’s not only a population health issue, it’s an individual patient safety issue,” Crnich says.
REFERENCE
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CMS. Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities. Fed Reg July 16, 2015: http://1.usa.gov/1hIe6Du
