By Paul Gallese, PT, MBA
As COVID-19 daily mortality figures peak and begin to decline in many parts of America, more attention is being turned to the post-acute care that a high percentage of COVID-19 survivors will need. While data on COVID-19 patients requiring post-acute care are limited, Medicare data suggest that about 30 percent of the patients recovering from sepsis, which has an inpatient mortality rate similar to COVID-19, require care at a skilled nursing or long-term care facility (Murthy, et al., 2020; Buchman, et al., 2020).
An influx of COVID-19 survivors will place additional strains on post-acute care facilities, which had an average occupancy rate of 85 percent at the beginning of the pandemic (Medicare Payment Advisory Commission, 2019). In addition to the capacity issue, introducing COVID-19 survivors, some of whom may remain contagious, into post-acute settings is fraught with difficult challenges. These facilities have been designed to encourage interaction among residents and visitors, not isolate them. Containing the spread of infections will require post-acute facilities to rethink their care processes, workflow and environmental design.
Articles published recently in the Journal of the American Medical Association (Grabowski & Maddox, 2020), Health Affairs (Dafny & Lee, 2020) and the Advisory Board (Buys and Westhead, 2020) explore these challenges in detail and put forth suggestions on how organizations operating post-acute care facilities can adapt. The content of these publications focuses mainly on developing safe and efficient hospital-to-post-acute transition strategies. In this Vitalacy blog post, I will focus on the importance of achieving better infection control in post-acute care environments.
A spotlight will be placed on hand hygiene compliance and infection control performance
On March 23, the Centers of Medicare and Medicaid Services (CMS) announced the start of new, focused infection control surveys intended to assess nursing homes’ compliance with infection control requirements to ensure they are prepared to address the threat of COVID-19 and other infections. More than 380,000 people die of infections in long-term care facilities each year, according to the Centers for Disease Control and Prevention (CDC, 2020).
During the first round of surveys conducted the week of March 30, 2020, CMS state surveyors found that 36 percent of nursing home facilities did not follow proper hand-washing protocols and 25 percent did not properly use personal protective equipment (PPE), according to an April 2 CMS press release.
In addition, a Los Angeles Times (2020) analysis of Los Angeles County nursing home data found that 89 percent of skilled nursing facilities battling coronavirus outbreaks had previous infection control violations, including mishandling patients with highly contagious bacterial infections, and not properly cleaning ventilators and other equipment.
This increased attention on infection control in nursing homes spurred by COVID-19 adds to a growing consensus on the need to improve hand hygiene in all healthcare settings. In an acknowledgement of electronic compliance monitoring technology becoming an “important component of a comprehensive hand hygiene program,” the Leapfrog Group added electronic monitoring to its hand hygiene practice standards for 2019 (Nour-Omid, 2020). Electronic hand hygiene monitoring technology has resulted in better compliance for many healthcare organizations, and the correlation between compliance and lower infection rates has begun to be demonstrated (Banks, et al., 2019; Michael et al., 2017; Kelly et al., 2016).
The same Bluetooth-enabled technology used for electronic hand hygiene compliance monitoring can be implemented to monitor the workflow of post-acute care staff, as well as to perform contact tracing to identify employees who must be separated from others. The data gathered from monitoring can provide insights into how workflow can be made more effective and how purposeful rounding can help to reduce healthcare-acquired conditions such as injuries due to falls, bedsores, and deep vein thrombosis.
Improving training, sick leave benefits and working conditions for post-acute care staff is imperative
Media stories about the lack of PPE on hospital COVID-19 units, followed by reports of healthcare workers becoming ill and dying of the disease, will make finding workers to staff post-acute care units more challenging than ever before. Demonstrating the safety of working conditions to potential new workers will be crucial. It will be important to educate workers about the importance of hand hygiene and to train them in proper hand washing methods. It also will be essential to provide them with PPE and to teach them how to use it correctly. Proper hand hygiene and PPE use, as well as regular vital signs monitoring, will help to decrease the spread of infections and reduce absenteeism and turnover.
A study by Strauch, et al., 2019 found that an electronic hand hygiene system in a hospital emergency department was associated with decreased absenteeism among emergency room nurses and technicians. The reduced absences resulted in less overtime hours worked by substitute staff and an unanticipated return on investment benefiting the health of employees.
Providing paid sick leave and health insurance to workers also will help to assure a quality workforce. Excellent working conditions and safety precautions will encourage workers laid off from other jobs during the present economic downturn to take jobs in post-acute care.
Specialized post-acute environments to treat contagious COVID-19 patients are being developed
Keeping COVID-19 patients safely away from uninfected patients and staff is of utmost importance; all patients entering a post-acute facility must be tested for COVID-19 whether they were treated for it at the hospital or not. This is important because experts remain uncertain about how long recovered patients remain contagious.
Specialized post-acute care environments is an idea taking root across the nation as a way to reserve capacity for non-COVID-19 patients while separating them from contagious patients. For example, a Massachusetts nursing home recently transferred non-COVID-19 patients to a different home and became a COVID-19-specific facility (Berger, 2020). Other kinds of facilities that can be transitioned into these specialized environments include recently shuttered hospitals or nursing facilities and military bases, hotels or college dormitories.
No matter where patients receive care in the post-COVID-19 world, infection control must be top of mind among all staff. That starts with the simple things – hand hygiene, safe working conditions, and continual testing. Vitalacy remains committed to providing infection control solutions that make healthcare facilities safer for patients and workers.
Banks M, et al. Decreased laboratory-identified Clostridioides difficile Infections with implementation of an electronic hand hygiene monitoring system in a long-term acute care hospital. Open Forum Infectious Diseases, 2019 supplement;6:S425-S425.
Berger L. Massachusetts nursing home blazes trail by emptying out to become COVID-19-specific facility. McKnight’s Long-Term Care News, March 31, 2020.
Buchman T, et al. Sepsis among Medicare beneficiaries: 2. The trajectories of sepsis, 2012-2018. Critical Care Medicine, March 2020;48(3):289-301.
Buys C & Westhead M. The missing piece of your Covid-19 capacity strategy: post-acute care. Advisory Board Daily Briefing, April 17, 2020.
Centers for Disease Control and Prevention (CDC) website. Nursing homes and assisted living (Long-term care facilities, April 30, 2020.
Centers for Medicare and Medicaid Services press release. CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19, March 23, 2020.
Centers for Medicare and Medicaid Services press release. Trump administration issues key recommendations to nursing homes, state and local governments. April 2, 2020.
Dafny L & Lee SS. Designating certain post-acute care facilities as COVID-19 skilled care centers can increase hospital capacity and keep nursing home patients safer. Health Affairs blog, April 15, 2020.
Dolan J & Mejia B. Coronavirus is attacking nursing homes with poor infection track records in L.A. County, Los Angeles Times, April 14, 2020.
Grabowski DC & Joint Maddox KE. Postacute care preparedness for COVID-19. Journal of the American Medical Association, published online March 25, 2020
Kelly JW, et al: Electronic hand hygiene monitoring as a tool for reducing healthcare-associated methicillin-resistant Staphylococcus aureus infection. American Journal of Infection Control, 2016;44:956–957.
Medicare Payment Advisory Commission. Report to Congress: Medicare payment policy—skilled nursing facility services. News release. Published March 15, 2019. Accessed March 20, 2020.
Michael H, et al: Durable improvement in hand hygiene compliance following implementation of an automated observation system with visual feedback. American Journal of Infection Control, 2017;45:311-313.
Murthy S, et al. Care for critically ill patients with COVID-19. Journal of the American Medical Association, published online March 11, 2020.