Journal Club: Remote infection control assessments in long-term care facilities during COVID-19 pandemic in Texas, 2020

JOURNAL CLUB REVIEW: REMOTE INFECTION CONTROL ASSESSMENTS IN LONG TERM CARE FACILITIES SUMMARY

This article, Remote Infection Control Assessments in Long-term Care Facilities (LTCF) during COVID-19 Pandemic in Texas, 2020,¹ reported the results of remote infection control assessments (tele-ICARs) performed predominately in nursing homes and/or skilled nursing facilities (NH/SNF) and assisted living facilities (ALF) in both a proactive and responsive fashion by the Texas Department of State Health Services (DSHS) during the SARS-CoV-2 pandemic. The results from 438 LTCFs tele-ICARs conducted using a standardized assessment tool during the first 8 months of the COVID-19 pandemic (March – October 2020) were analyzed.

The primary objective was to identify differences in infection prevention and control (IPC) knowledge and practices across LTCF types and inform educational efforts for these facilities. An additional objective was to determine the feasibility of conducting tele-ICARs. Findings from proactive and outbreak responsive tele-ICARs include gaps in the proper use of Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene, disinfectant use and education, communal dining and activities, and compliance auditing for hand hygiene and personal protective equipment (PPE) practices. LTCFs with responsive tele-ICARs reported a significant difference in preference for alcohol-based sanitizer to soap and water hand hygiene, had suspended communal dining and group activities and had designated cohort isolation space when compared to LTCFs who had proactive tele-ICARs. Proactive tele-ICARs performed prior to identified COVID-19 cases were less likely to have dedicated space to house or cohort residents with infection. Significantly more ALF than NH/SNF had not suspended communal dining activities nor provided designated cohort isolation space. These findings can help inform IPC practice in LTCFs with focused education on CDC hand hygiene recommendations, the importance of social distancing, appropriate disinfectant use, and the preparation of designated spaces for the care of infected residents before an outbreak. The authors concluded that performing tele-ICARs in LTCFs enables public health agencies to provide direct and individualized feedback to facilities and identify state-wide opportunities for effective interventions in response to SARS-CoV-2.

ARTICLE OVERVIEW

Residents in LTCFs are increasingly vulnerable to infection, and these facilities are often found deficient in infection and prevention control practices.² The ICAR tool was developed in response to the Ebola outbreak as a systematic method to assess infection prevention preparedness in skilled nursing homes.³ During the COVID-19 pandemic, a modified remote ICAR (tele-ICAR) was developed. These assessments can be conducted before cases are identified in the LTCFs (proactive) or in response to a facility outbreak (responsive).

The Texas DSHS offered proactive and responsive tele-ICARs to LTCFs across their eight public health regions. During the 8-month study period, 438 LTCFs voluntarily participated (264 proactive and 174 responsive). Infection prevention knowledge gaps identified in both proactive and responsive assessments included a preference for soap and water (rather than alcohol-based hand sanitizer as per CDC recommendation), the contact time for disinfectants, need for suspension of communal dining, the value and necessity for infection prevention audits, need to curtail communal group activities and preparation of dedicated space to cohort residents with COVID-19 infections. As previously summarized, ALF was significantly less likely to have stopped communal dining or have a space to cohort COVID -19 residents when compared to NH/SNF. Further, LTCFs who had proactive tele-ICARs were less likely than those that received responsive tele-ICARs to be compliant with published core IPC guidelines, for example, alcohol-based hand sanitizer over soap and water for hand hygiene or recommended SARS-CoV-2 prevention guidelines, for example, suspension of communal dining and group activities, identification of a dedicated cohort isolation space. The authors concluded that despite conducting the ICARs remotely, they gleaned important information about infection prevention knowledge and practice gaps and provided important and timely education regarding recommended SARS-CoV-2 prevention and outbreak mitigation guidelines.

DISCUSSION AND LIMITATIONS

This article was well-written and methodologically sound. A brief but sufficient up-to-date background on infection prevention in LTCFs and the ICRA process was provided. The authors met their objectives and provided feasibility data on how to conduct tele-ICARs successfully. Acronyms were first summarized to help those unfamiliar with these facilities to clarify their meaning.

The research questions were explicitly stated. The authors solicited a volunteer sample of LTCFs to participate in the tele-ICARs who were not experiencing a COVID-19 outbreak (proactive) and those who were experiencing an outbreak (responsive). It was unclear how many proactive and responsive LTCFs were eligible to participate, and no response rate was reported. As this was a convenience sample, it was not as rigorous a design as conducting a random sample of LTCFs.⁴ One limitation may be that LTCFs who volunteered for the tele-ICARs were either better or less prepared than LTCFs who did not volunteer to participate. The authors did not mention Institutional Review Board approval (IRB); however, as this project was initiated as a process improvement initiative, IRB oversight was unnecessary.

The authors provided a copy of the ICAR tool domains and measures in the appendix. This may be particularly helpful for infection preventionists (IPs) who want to replicate this work. The data was analyzed using a Fisher's Exact test followed by Bonferroni correction for multiple comparisons. Significant associations were added to a logistic regression model to characterize the relationship. Tables were provided with the results. However, the main tables in the article only included Fisher's exact test p values without Bonferroni correction. This may be somewhat misleading for those who do not thoroughly explore the article.

The authors provide a good discussion that relates the article's findings to the literature and the relationship to IPC practice in LTCFs. Most limitations were addressed, including that different epidemiologists and infection preventionists conducted the tele-ICARs. While this study was conducted in Texas, it contributes to the knowledge about gaps in LTCF IPC practices and provides a novel approach for conducting IPC assessments during a pandemic. Information from this study may assist LTCFs with developing and implementing best practice procedures that incorporate the CDC guidelines for hand hygiene, PPE compliance monitoring, selection of disinfectants, and social distancing during outbreaks. Interestingly, these results are similar to a previously published article from the CDC Tele-ICAR Team.⁵ In that study, which included 629 LTCFs Tele-ICAR consultations across 19 states, 68% of the facilities identified gaps in core IPC practices: 39% of the facilities failed to follow CDC recommendations for hand hygiene, and 24% had gaps in environmental cleaning policies and procedures (failure to follow contact times appropriately). In addition, they reported that communal practices were infrequently suspended: 6% stopped group activities inside the facility and field trips, 7% stopped communal dining, and only 3% of facilities encouraged residents to remain in their rooms.⁵

IMPLICATIONS AND CONCLUSIONS FOR INFECTION PREVENTIONISTS

This article identified that LTCFs need increased education regarding IPC practices, especially during a pandemic. To ensure that this vulnerable population is being cared for with IPC best practices, ICAR assessments may be helpful. In most cases, on-site ICARs are recommended.⁶ However, this article described a successful method for conducting tele-ICARs. While a tele-ICAR is not intended to replace the on-site assessment, IPs could use the remote method during a pandemic or as an interim or follow-up assessment when on-site visits are not feasible. The ICAR further assists the facility in addressing the root causes of incorrect or suboptimal IPC practices, which promotes the protection of residents and staff from not only COVID but other infectious diseases as well.⁵

While this study was conducted in Texas LTCFs, the knowledge and practice gaps identified are similar to those described in the literature and can be used to help IPs tailor LTCF educational efforts. This study revealed that the most common gap in LTCFs was a preference for soap and water hand hygiene compared to the CDC-recommended alcohol-based hand sanitizer. They hypothesized that this gap might result from misunderstanding the difference between community and healthcare settings. These findings underscore the need for IPs to continue to educate LTCFs on the CDC guidelines for hand hygiene.

Another finding from this study, which validates a gap identified by previous investigators, was a lack of understanding about disinfectants, particularly the importance of contact time. This is a significant knowledge gap for these facilities where rigorous environmental disinfection protocols are necessary to prevent the transmission of epidemiologically important pathogens. Failure to adhere to the manufacturer's instructions for use and the recommended contact time may interfere with the product's efficacy. The authors suggested that multidisciplinary team communication and sustained education, including the environmental services vendor and staff, are needed to address this gap.⁷

A unique aspect of LTCFs is communal dining and group activities. While this approach promotes social interaction for the residents, it presents a risk when IPC mitigation strategies are required, especially during a pandemic. At the beginning of the pandemic, the CDC recommended that group activities be canceled.⁸ However, as the pandemic continued, guidance was continually updated. The constant flow of information can be challenging in LTCFs, where staff are already overworked, and understaffing is addressed by agency personnel unfamiliar with the facility. IPs can help LTCFs adapt to innovative approaches to communal activities such as staggering mealtimes and social distancing. Involving the team, especially nursing assistants, would help create strategies that keep patients safe while not overburdening staff.

This study also identified the lack of a cohortation plan. Like communal dining, LTCFs are designed to provide a casual ‘home’ environment where private rooms are not routinely available. Cohorting infected residents can be highly disruptive to residents and staff and significantly affect workload. Developing a cohort plan in advance of an outbreak is ideal and a required element of LTCFs emergency preparedness policy. IPs may need to be creative in their approach and recognize that private rooms are generally not available or feasible, and identifying a unit or part of a unit for cohortation is necessary.

Acknowledgments

This Research Committee Commentaries: Implementation Science Commentary is part of the ongoing activity of the Association for Professionals in Infection Control and Epidemiology Research Committee. The primary purpose of this section in AJIC is to direct and support readers regarding how to evaluate the relevance and implications of a study for implementation in their own setting. The Research Committee presents an assessment of the study quality and study relevance of select articles.