key: cord-0072500-3a8mxrp8
authors: Bonner, Alice; Resnick, Barbara
title: Changing the dynamic: What can we learn from infectious disease management in long-term care settings?
date: 2021-12-28
journal: Geriatr Nurs
DOI: 10.1016/j.gerinurse.2021.12.008
sha: 78f6aa8dcbfa7a0087cc7a02edf89efae345c47d
doc_id: 72500
cord_uid: 3a8mxrp8

nan

Changing the dynamic: What can we learn from infectious disease management in long-term care settings?

Although we deal with many infections in long term care settings, the past year and a half has left us focused on COVID-19 infections and the prevention, management, and impact of this infection. By now, many of you have reviewed articles or position papers on how the 2020/2021 COVID-19 pandemic affected care delivery and staffing levels in U.S. nursing homes. Those of us who have practiced through H1N1, annual influenza outbreaks, outbreaks of clostridium difficile, hurricanes, blizzards, and other natural disasters, have come to appreciate the need for emergency preparedness and response systems that support patients, residents and healthcare workers, particularly those working in nursing homes and other long-term care settings.

In this GN Special Issue, we present papers that highlight how the COVID-19 pandemic caused infections and illnesses in nursing home residents and challenged long-term care staff to prevent, mitigate and manage residents with mild to serious infectious disease. The virus took the lives of thousands of residents and staff members, leaving remaining staff and residents traumatized after losing friends and colleagues, living with the fear of not surviving a COVID-19 infection, and experiencing depression and anxiety due to social isolation and uncertainty about the future.

While we discuss approaches to the pandemic in terms of clinical practice, teamwork and workflow adaptations, regulatory waivers and temporary measures by state and federal agencies, larger questions about how we resource long-term care in the U.S. remain unanswered. Many health care leaders and the public are asking why we weren't better prepared to address a sudden pandemic in nursing homes. A more proactive question might be, "How do we adequately resource long-term care so that teams and leaders are better able to prevent, mitigate and manage infections that will happen from time to time and are easily spread in these settings?"

Papers presented in this Special Issue include descriptions of how teams, often led by nurses, implemented changes to delivery systems when evidence-based approaches were not always available due to rapidly changing information. As new data emerged each day and each week, the Center for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and other federal and state agencies tried to provide the latest recommendations on visitation, personal protective equipment (PPE), communication with the community, and evolving treatment options.

When COVID-19 vaccines became available, nursing homes sought guidance from federal and state agencies so that as many staff and residents as possible could be offered the vaccine. Vaccination rates among nursing home staff have been low in many parts of the country (30À50%), therefore programs to increase vaccine confidence and behaviors (being willing to receive the vaccine) have been widely promoted.

Initiatives funded by the Health and Human Services (e.g., The CARES Act), the Agency for Health Care Research and Quality (AHRQ) and the University of New Mexico's Project ECHO in partnership with the Institute for Healthcare Improvement (IHI) and other national organizations have helped to address the COVID-19 pandemic in nursing homes. Project ECHO identified a number of issues such as lack of up-to-date information on how the virus is spread, how to implement interventions to reduce spread of COVID-19 within each nursing home, proper use of PPE, hand washing, social distancing, and cohorting of infected residents and staff. Methods to bring information rapidly to all U.S. nursing homes were identified, and over half of U.S. nursing homes (about 9000) participated in at least one phase of Project ECHO over several months. 1 The COVID-19 pandemic highlighted once again that most nursing homes and assisted living communities do not have adequate resources to respond to a sudden shift in resident care needs due to public health emergencies. The trauma of the pandemic that significantly impacted long term care staff well-being and increased rates of turnover among certified nursing assistants (CNAs), nurses, and other nursing home workers resulted in even more stress and burnout among that workforce. 

Geriatric Nursing 000 (2021) 1À2

Geriatric Nursing journal homepage: www.gnjournal.com A number of recent approaches have been developed to promote infrastructure improvements in order to better deliver age-appropriate care and to support clinical and administrative staff across settings. One example is the Age-Friendly Health Systems and the 4Ms Framework (the 4Ms include What Matters, Medications, Mentation, and Mobility). By addressing each of the 4Ms, and the 4Ms as a set, clinical teams can cover most aspects of care delivery to promote and optimize critical components of care and promote care that is person-directed and best meets the needs of each individual. 2 Long term care communities that have adopted Age-Friendly principles and practices are well positioned to respond to infections at the individual level or during a pandemic 3 as Age-Friendly principles keep the focus on the basic needs of the individual. Focusing on What Matters to the individual, using only appropriate Medications, optimizing Mentation, and maintaining or improving Mobility and highest level of function are basic interventions and promote quality of life through acute infections and the impact of these infections both short and long term. Without such a guiding framework and standardized, fundamental practices, long term care teams may be left without ways to cope with new challenges affecting a large number of residents and staff members. 4 Using COVID-19 as an example of how to apply the 4Ms framework to nursing home workflows, one of the first approaches would be to ask each resident (and when appropriate, care partner/s) about What Matters to them, given the COVID-19 infection and illness. What are their goals and wishes should their condition change significantly, either for better or worse? For example, many of us called families and spoke with all residents about their advance directives in light of COVID-19 and whether or not they wanted to be transferred to the hospital should they become COVID-19 positive. Goals and wishes should also be documented in care plans or service plans for everyone on the team to see and act on.

During COVID-19, we took the time to review Medications and de-prescribe those that were not necessary and/or not appropriate for the individual given guidelines, age, potential side effects and resident and family preferences. Related to Mentation, older adults with infections are at high risk for delirium and worsening of cognitive function and associated behavioral symptoms; therefore early prevention and management strategies became even more important. And finally, carefully considering the value of limiting opportunities for physical activity for older adults within long-term care settings during periods of infection (e.g., isolation of residents with Shingles) or as prevention during pandemics such as with COVID-19 should be done. The risks/benefits of such restrictions need to be based on a careful evaluation of the resident's preferences and the safety of the entire community.

In addition to specific care approaches, it is high time that we use the lessons learned during this latest public health emergency to reform how we pay for long-term care in the United States. We must invest in leadership training and ongoing support and mentoring for long-term care leaders. We must promote careers in long-term care in schools of nursing and among nursing faculty as well as in other professional programs (e.g., medicine, social work, pharmacy, etc.). We must transform the CNA role into a job that enables people to support themselves and their families with adequate resources, accessible training, personal fulfillment, and productive, positive relationships within the workplace. For some, professional development and growth opportunities within the CNA role and a career ladder that will inspire people to want those jobs is also important. We must respect those in this position, acknowledge their voices and care of residents and reimburse CNAs appropriately for their work.

Let's come together to build a sustainable infrastructure so that long-term care professionals can respond appropriately with skills and knowledge when infections and pandemics impact all of us.

Hope Springs Eternal: can Project ECHO Transform Nursing Homes?

Age-Friendly Nursing Homes: Opportunity for Nurses to Lead. Nursing Clinics of North America

Evidence for the 4Ms: interactions and Outcomes across the Care Continuum