key: cord-1028763-bih7v21y
authors: Walters, Maroya Spalding; Prestel, Christopher; Fike, Lucy; Shrivastwa, Nijika; Glowicz, Janet; Benowitz, Isaac; Bulens, Sandra; Curren, Emily; Dupont, Hannah; Marcenac, Perrine; Mahon, Garrett; Moorman, Anne; Ogundimu, Abimbola; Weil, Lauren M.; Kuhar, David; Cochran, Ronda; Schaefer, Melissa; Slifka, Kara Jacobs; Kallen, Alexander; Perz, Joseph F.; Adeyemo, Adesubomi; Bagchi, Suparna; Boone, Karen; Allen-Bridson, Katherine; Cali, Susan; Carmon, Clayton; Chisty, Zeshan; Duffy, Nadezhda; Epstein, Lauren; Goswami, Neela D.; Ham, D. Cal; Hannan, Judy; Hercules, Margaret; Issa, Anindita; Kolwaite, Amy; Legros, Jessie; Lees, Serina; Lucas, Todd; Matanock, Almea; McClung, Nancy; Moro, Pedro; Nanduri, Srinivas; Shugart, Alicia; Sipe, Theresa; Smith, Henrietta; Soda, Elizabeth; Somers, Tarah; Umeakunne, Erica; Tucker, Pattie; White, Katelyn
title: Remote Infection Control Assessments of U.S. Nursing Homes During the COVID-19 Pandemic, April to June 2020
date: 2022-04-06
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2022.03.015
sha: 658f060c67dc8311ec968dd173afea981b87893c
doc_id: 1028763
cord_uid: bih7v21y

Nursing homes (NH) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NH were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff. Objective To assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps. Design We incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering six domains: visitor restrictions; healthcare personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility. Setting and Participants Health department-referred NH that agreed to TeleICAR consultation. Methods We assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment. Results During April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NH across 19 states. Overall, 524 (83%) had ≥1 implementation gaps identified; the median number of gaps was 2 (IQR: 1, 4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625 [68%]) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620 [47%]). Conclusions and Implications TeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NH across the U.S. early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

Early in the emergence of SARS-CoV-2, the virus that causes COVID-19, nursing homes (NHs) 36 were identified as settings at high risk for transmission. NHs are licensed residential healthcare 37 facilities that care for persons with chronic illness or disability; most provide skilled nursing Preventing the introduction and spread of SARS-CoV-2 in NHs has been a national public health 46 priority since the beginning of the U.S. COVID-19 response. In March 2020, the U.S. Centers for Disease Control and Prevention (CDC) released key strategies for NHs to prevent introduction 48 and spread of SARS-CoV-2 6 and developed a standardized infection control assessment and 49 response (ICAR) tool to assist health departments and NHs in assessing NH implementation of 50 COVID-19 preparedness and core infection prevention and control (IPC) practices. 7 To reach 51 many facilities rapidly, we developed strategies to perform assessments by telephone and 52 video conferencing (referred to as TeleICAR) and provide immediate feedback. Here, we 53 present findings from these remote assessments, including describing common gaps in 19 preparedness in NHs and illustrating the potential utility and limitations of remote 55 assessments for understanding and improving IPC. using shorter visits without the need to travel onsite. 69 We developed the TeleICAR tool for NH Table 4) . Twenty-six 208 (17%) facilities reported wanting to make changes to policies and practices after the TeleICAR 209 consultation but had been unable to implement the changes prior to the follow-up call. Infection prevention in nursing homes was a growing concern prior to the COVID-19 pandemic. 264 CMS has steadily increased requirements for IPC implementation by NHs and since 2016 has 265 required NH to designate one or more individuals responsible for IPC at the facility (e.g., full-or gave responses they knew to be correct rather than describe actual practice; the potential for 305 such bias supports the preferential use of video in assessments. Some elements, such as ABHS 306 availability in resident rooms and adherence to social distancing and room restrictions, were 307 challenging to observe even by video, due to privacy concerns and the short nature of the 308 interaction. We conducted remote assessments at a convenience sample of 629 facilities, a 309 fraction of the >15,000 NHs nationally. Health departments additionally conducted several 310 thousand NH ICARs, both in-person and remotely, from March-July 2020, and data from those 311 assessments are not included here and are not available for analysis. Likewise, we conducted 312 follow-up at a sample of facilities; although follow-up was performed by individuals not 313 involved in the original assessment or in nursing home regulatory activities to reduce social 314 desirability bias, responses may have been biased toward reporting changes. We were unable 315 to evaluate the extent of changes or whether they were sustained throughout the pandemic. 316 Facility referrals among jurisdictions that requested TeleICAR assistance reflected a range of 317 factors including local COVID-19 incidence, CMS quality rating, and history of past outbreaks or 318 infection control gaps. Therefore, although our findings highlight common themes, they are not 319 generalizable. Future studies may consider comparing remote assessments to in-person 320 assessments for both identifying gaps and assessing changes in response to recommendations. J o u r n a l P r e -p r o o f Table 3 . Themes among nursing homes preparing for COVID-19 and participating in remote infection control consultations, among infection control domains where ≥15% of facilities had one or more gaps.

• Often unable to provide medical clearance and fit testing for N95 respirators. • Provided pay incentives to retain and reward staff while others supplemented healthcare providers through staffing agencies.

• Performed at least some symptom screening activities for non-ill patients more often than minimum recommendation (e.g., every shift rather than daily). • Tracked oxygen saturation in addition to routine, recommended assessment for symptoms of COVID-19. • Unaware of or had not yet implemented additional symptoms added to CDC guidance in May 2020 (among facilities that performed screening and were assessed after guidance update). • Had difficulty assessing residents with communication difficulties (e.g., dementia, non-verbal). • Reported that residents with dementia had difficulty using a cloth face covering or facemask for source control and staying in their room. • Described safety concerns about keeping doors closed for rooms of residents with fall risks. • Residents requiring feeding assistance eat in the dining room using social distancing, while other residents have meals in their rooms.

• Implemented PPE optimization strategies but often did not understand when or how to safely implement these strategies. • Described using crisis capacity PPE strategies a in the absence of a shortage. • Locked up PPE or limited availability due to concern for or evidence of theft. • Sought alternative approaches to usual suppliers to manage shortages, including recruiting volunteers to sew launderable gowns, purchasing supplies from local retailers and reimbursing staff. • Substituted clothing items (e.g., rain ponchos) for isolation gowns.

• Described using excess PPE including shoe and hair covers.

• Attempted to disinfect used N95 respirators, face masks, and isolation gowns by spraying with disinfectant or exposing to ultraviolet light prior to reuse.

• Reported difficulty obtaining ABHS and ABHS dispensers. Multiple facilities reported receiving ABHS compounded by local distilleries. Facilities would reuse and refill single use ABHS bottles and ABHS dispensers. • Staff unaware of contact time for EPA-registered disinfectants or provided inappropriate contact times for products. a Crisis capacity: Strategies that are not commensurate with U.S. standards of care but may need to be considered during periods of known PPE shortages. Crisis capacity strategies should only be implemented after considering and implementing conventional and contingency capacity strategies. Facilities can consider crisis capacity strategies when the supply is not able to meet the facility's current or anticipated utilization rate. 25

Severe Outcomes Among Patients with Coronavirus 341 Disease 2019 (COVID-19) -United States

COVID-19 in a Long-Term Care Facility -King 344

Morbidity and Mortality Weekly Report

Nursing Home Care in Crisis in the Wake of COVID-19

Epidemiology of Covid-19 in a Long-Term Care

COVID-19 Nursing Home Data

 Table 4 . Changes in nursing home knowledge and practices in a randomly selected subset of facilities following remote infection control consultations, n=154 No./n (%) Increased understanding of one or more practices for preventing COVID J o u r n a l P r e -p r o o f