Leadership

1. What resources (physical, human, financial) are needed to meet the goals of the nursing home’s IPC program?

Recommendation: The resources for a nursing home’s IPC program should include:

1. 1. At least one infection preventionist (IP) to manage the infection prevention and control (IPC) program who:

   1. a. Has ongoing, specialized training in IPC that is financially supported by the nursing home

   2. b. Demonstrates commitment to ongoing continuing education in IPC to remain current in developments and strategies to optimize the IPC program

   3. c. Has clinical and/or public health experience

   4. d. Is an effective communicator, educator, leader, mentor, and collaborator

   5. e. Receives training in leading and managing programs

2. 2. Sufficient dedicated time for the IP(s) to manage the IPC program based on the complexity of the resident population and services provided:

   1. a. At least one full-time equivalent (FTE) IP, if the facility has more than 100 licensed beds or provides onsite ventilator or hemodialysis services

   2. b. At least 0.5 FTE IP (20 IP hours per week), if the facility has fewer than 100 beds and does not provide on-site ventilator or hemodialysis services

3. 3. Adequate staffing (e.g., nursing, clinical) and supplies (e.g., personal protective equipment [PPE], alcohol-based hand sanitizer [ABHS], US Environmental Protection Agency (EPA)-registered disinfectants) to allow healthcare personnel (HCP) to follow all recommended IPC practices

4. 4. Dedicated time for personnel to receive regular job-specific IPC education and demonstrate competency through assessment (see 14 and 15)

5. 5. Access to information technology training and infrastructure (e.g., integrated electronic health records, software applications, internet access) to support facility-level surveillance activities and access to public health surveillance programs

6. 6. Access to expert advice, learning collaboratives, and professional associations specific to IPC (see 6, 9, and 42).

Rationale: In 2016, the Code of Federal Regulations (483.80) ¹⁸ required that all Centers for Medicare and Medicaid Services (CMS)-certified nursing homes have a designated person overseeing the IPC program. This person should be an IP with a scope of practice ^{Reference Manning, Borton and Rumovitz19} that includes IPC knowledge and skills and clear expectations to implement best practices. Although these practices should be tailored to the population and resources, they should also be built on core IPC practices outlined in CDC guidance and should be adherent to CMS requirements.

The individual overseeing the IPC program should have dedicated support from nursing home administrative and medical leadership, including the medical director, and the organization’s commitment to provide the financial resources to meet the growing scope of the IPC program. Program responsibilities include developing policies and procedures to implement the most current, evidence-based practices, using electronic systems for infection surveillance and reporting, informing HCP IPC training, auditing IPC practices, guiding outbreak preparedness, prevention, and response, promoting antimicrobial stewardship, participating in quality assurance activities, and leading quality improvement projects to improve IPC practices.

Staffing

Although no recent studies are available that quantify IP hours for all levels of nursing home care, a nursing home should provide adequate IPC personnel, time, and resources in accordance with the level of acuity and services provided to residents. For example, chronically ventilated nursing home residents are at greater risk for infection. Bundled interventions (a defined set of evidence-based practices) put in place by the IP may decrease rates of ventilator-associated pneumonia. ^{Reference Finch Guthrie, Rayborn, Boatright, Pearson, Wieting and Peterson20,Reference Shitrit, Meirson, Mendelson and Chowers21} Residents who are ventilated are at risk for high rates of MDRO colonization and may benefit from admission screening to assist with early identification and appropriate isolation, ^{Reference Pacilli, Kerins, Clegg, Walblay, Adil and Kemble22} especially with the emergence of Candida auris and carbapenem-resistant Acinetobacter baumannii in nursing homes that provide ventilator services. ^{Reference McKinnell, Singh, Miller, Kleinman, Gussin and He6,Reference Harris, Pineles, Johnson, O’Hara, Smith and French23–Reference Perencevich, Stone, Wright, Carmeli, Fisman and Cosgrove27}

Of note, specific staffing requirements for IPs may vary depending on the size and complexity of the facility, as well as the local and state regulations. The National Academies of Sciences, Engineering, and Medicine have recommended that the IP have sufficient time to perform required duties; one survey found approximately 25% of IP time is spent on infection surveillance. ^{Reference Pogorzelska-Maziarz and Kalp28} Submitting surveillance data to a network, which allowed for comparing infection rates across facilities and tracking performance improvement, has been associated with a decreased rate of healthcare-associated infections (HAIs), including influenza-like illness, urinary tract infections (UTIs), and pneumonia over time. ^{Reference Haenen, Verhoef, Beckers, Gijsbers, Alblas and Huis29} This important and time-intensive responsibility is one of numerous responsibilities, including the IP’s engagement in continuing education and need to train and educate nursing home personnel in IPC. ^{Reference Herzig, Dick, Sorbero, Pogorzelska-Maziarz, Cohen and Larson30}

As part of guidance issued during the COVID-19 pandemic, CDC recommended at least one full-time IP for every 100 beds or for any nursing home that provides dialysis or mechanical ventilation. ³¹ Some states legislate FTE IPs for each nursing home. In New Jersey, nursing homes with 100 residents or more must have a full-time IP in a manager position and each nursing home must have an IPC committee. ³² California has legislated that each nursing home must have a full-time IP. ³³ In light of the evolving expectations for nursing home IPC programs and the increasing complexity of the resident population, nursing homes larger than 100 licensed beds and those that provide onsite ventilator or hemodialysis services should have at least one FTE IP. If a facility has fewer than 100 beds or does not provide these services, a nursing home should have at least 0.5 FTE IP.

Training

IPs who work in nursing homes should have specialized training in infection prevention and control. A national survey of US nursing homes found that facilities that have IPs with specialized IPC training (certification in infection control, state or local training course with certificate, national or local training course through a professional society, or other) were more likely to have recommended IPC policies in place, when controlling for other known measures of quality (e.g., ownership, staffing). ^{Reference Agarwal, Dick, Sorbero, Mody and Stone14} Agarwal and colleagues also found a positive association between nursing homes that employ trained IPs who have certifications and nursing homes having a comprehensive antimicrobial stewardship program. ^{Reference Fu, Mantell, Stone and Agarwal34} Prior to the CMS regulation for IPC, Wagner and colleagues did not find a specific correlation between IPC training and nursing home quality measures. However, this correlation could strengthen as more directed training and efforts to build a foundation for IPC in the nursing home occurs. ^{Reference Wagner, Roup and Castle35} This group did find that having a FTE IP was associated with better outcomes in 3 of 8 quality measures (percent high-risk residents with pressure ulcers, percent influenza vaccination for long-stay residents, and percent influenza vaccination for short-stay residents).

The National Academies of Sciences, Engineering, and Medicine recommends that every nursing home has an IP who is a registered nurse (RN), advanced practice RN, or a physician ³⁶ and must have received specialized IPC education. However, other research has found that the effect of specialized training was not dependent on whether the IP was a RN. Therefore, since many IPs come from public health and other clinical backgrounds, the IP position does not need to be limited to only a RN or physician.

Resources

A business case should be used as a tool to support advocating to nursing home leadership for resources. ^{Reference Hutton, Krein, Saint, Graves, Kolli and Lynem25,Reference Perencevich, Stone, Wright, Carmeli, Fisman and Cosgrove27} For IPC programs to be successful, the nursing home should have adequate IP and nurse staffing to reduce rates of infections, ^{Reference Hutt, Radcliff, Liebrecht, Fish, McNulty and Kramer24} which often requires programs to improve retention of personnel. The nursing home should ensure that ample quantity of IPC supplies (e.g., PPE, ABHS, EPA-registered disinfectants) is available in resident care areas to allow HCP to follow all recommended IPC practices. The IP also needs access to information technology training and infrastructure (e.g., integrated electronic health records, software applications, internet access) to support collection and management of infection surveillance and other resident outcome data used to inform performance improvement. ^{Reference Hutt, Radcliff, Liebrecht, Fish, McNulty and Kramer24,Reference Alexander and Wakefield37–Reference O’Fallon, Harper, Shaw and Lynfield39} Technologic resources not only support data collection and management within the facility but also support a nursing home’s access and connectivity to regional population and laboratory-based public health surveillance programs. ^{Reference Guh, Bulens, Mu, Jacob, Reno and Scott40–43}

2. To whom should the nursing home IP report?

Recommendation:

1. 1. The nursing home IP should report to a designated person in administrative and medical leadership who has knowledge relevant to regulatory and resource needs for the IPC program.

2. 2. The IP should be a member of the Quality Assessment and Assurance (QAA) committee to integrate IPC activities within the quality assessment and performance improvement programs.

3. 3. To be successful, IPC programs require visible and tangible support from all levels of nursing home personnel:

   1. a. Administrative and medical leadership, including the medical director, should actively participate in IPC program activities to provide appropriate resources and training to support the implementation of IPC policies and procedures

   2. b. Nursing homes should clearly define the IP position and include dedicated time for the IP in IPC training, continuous education, and modes of communication with facility personnel, including leadership

   3. c. Nursing homes should evaluate IPC program surveillance reports and practices using the Quality Assurance Performance Improvement (QAPI) process.

Rationale:

Administrative and medical leadership and reporting structures

The nursing home should ensure that there is structured oversight of the IPC program with support for activities from administrative and medical leadership, including the medical director. Administrative leaders should provide financial resources to meet the training and continuing education needs of the IP and to procure supplies needed to implement IPC program activities. Medical leadership, including the medical director, should provide clinical insight into protocols, processes, and treatment needs and should be an active participant in the IPC program and regularly attend its meetings. ^{Reference Smith, Bennett, Bradley, Drinka, Lautenbach and Marx1,44}

Reporting structures for the IPC program and the ways that administrative and medical leadership engage may vary depending on the facility’s needs. In a review article, Montoya and colleagues suggested that facilities designate an administrator to be an active part of the team led by an IP. ^{Reference Montoya, Cassone and Mody45} In a qualitative study conducted in Canada during the COVID-19 pandemic, Yau and colleagues found that communication and coordination among leadership and personnel were essential to manage pandemic needs, in some instances involving daily huddles. ^{Reference Yau, Vijh, Prairie, McKee and Schwandt46} In a successful model described by Bartels and colleagues, the nursing home IP reported to a regional director of infection prevention in a large healthcare system. ^{Reference Bartles, Dickson and Babade47} With growing numbers of nursing home corporations, when available, IPC or quality leaders at the regional or national level of an organization should support and collaborate with nursing home IPs to develop standardized policies and practices. ^{Reference Perencevich, Stone, Wright, Carmeli, Fisman and Cosgrove27} Regardless of configuration, the IP and IPC program should have a reporting structure that facilitates communication with the medical director and leadership of relevant departments, including mechanisms to seek resources for the IPC program.

QAA committee, QAPI program, and IPC committee

In the United States, CMS requires that each nursing home facility maintain a QAA committee that meets at least quarterly and includes the director of nursing, the medical director or designee, at least three other staff members (one of whom must be in a leadership role), and the IP. ^18,48 CMS also requires that each facility conduct an annual review of the IPC program and update the program as necessary. Given that CMS requires the IP to report to the QAA committee, the members of the QAA committee are well positioned to review IPC policies. The IP should present and review the IPC policies with the QAA at least annually, discussing those for which modifications may be indicated due to internal data, new evidence, or changes to local, state, or federal guidance. The IP is responsible for documenting policy changes and associated dates, which will support the annual review process.

The QAA committee implements the QAPI program, intended to be a comprehensive, data-driven process to address outcomes of care and quality of life. Part of the QAPI program’s mandate is to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, all aligning with the activities of an effective IPC program. Although IPC should be integrated into QAPI, it is not the only safety and quality concern addressed by the program. Therefore, some nursing homes may decide to create a separate interdisciplinary IPC committee to focus on implementing the core activities of the IPC program. Even if an IPC committee exists, the IP should continue to serve on the QAA committee to generate support and resources for the IPC program. A strong synergistic relationship between a nursing home’s IP and the facility’s administrative and medical leadership, including the medical director, enhances alignment, adherence to IPC practices, and evaluation for additional changes presented for QAPI.

3. How can a nursing home support the continuity of its IPC program?

Recommendation: Nursing homes should implement strategies to retain and mentor HCP for IPC program continuity so that the IPC program is not dependent on one individual:

1. 1. Prioritize and invest in personnel retention strategies, including competitive wages and benefits for the IP

2. 2. Provide ongoing, job-specific IPC training due to the likelihood that turnover of HCP leads to decreasing effectiveness of the IPC program (see 14 and 15.)

3. 3. Establish a mentoring program to foster interest in IPC:

   1. a. Identify individuals who participate in quality improvement initiatives and/or demonstrate interest in IPC in interactions with nursing/clinical supervisors

   2. b. Provide incentives for both mentors and mentees

4. 4. Encourage and support participation in public health activities, local Association for Professionals in Infection Control and Epidemiology (APIC) Chapter meetings, and educational offerings from the Society for Healthcare Epidemiology of America (SHEA) and other professional organizations that work in IPC

5. 5. Develop processes for succession planning, transitions, and cross-training for the activities that support the IPC program (e.g., conducting surveillance, developing IPC policies, implementing antimicrobial stewardship)

6. 6. Reduce decision fatigue with checklists and standard processes

7. 7. Celebrate success and foster a team atmosphere.

Rationale: A nursing home should have a plan in place to ensure the continuity of the IPC program activities and stability in the IP position. In a study that evaluated nursing home IPC program characteristics linked with IPC deficiency citation data, nursing homes that received citations reported having IPs with less IPC experience in their facility and were less likely to provide financial resources for continuing education in IPC. ^{Reference Herzig, Stone, Castle, Pogorzelska-Maziarz, Larson and Dick49} Fu and colleagues found that IP turnover every 3 years or more was associated with a less comprehensive nursing home antimicrobial stewardship plan. ^{Reference Fu, Mantell, Stone and Agarwal34}

Although not specifically assessed in nursing homes, understanding the effects of financial factors, such as competitive wages and benefits and professional development support (e.g., investments in training opportunities), could inform efforts to recruit and retain IPs. ^{Reference Knighton, Gilmartin and Reese50,Reference Zoutman, Ford and Gauthier63} Additional strategies to develop and support IP staff identified through a survey of IPs across various healthcare settings include mentoring new IPs, systems to support healthy work environments, reward and recognition programs, and systems to assess and balance workload. ^{Reference Gilmartin, Smathers and Reese51}

Another issue that affects quality of care in nursing homes is instability among certified nursing assistants (CNAs) and nursing staff. ^{Reference Castle, Engberg and Men52} High turnover levels among nursing personnel in nursing homes (>70% per year) are associated with decreased ”compliance” of vital sign monitoring, physician notification, and appropriate hospitalization for pneumonia ^{Reference Hutt, Radcliff, Liebrecht, Fish, McNulty and Kramer24} and increased numbers of pressure ulcers, pain, and UTIs. ^{Reference Trinkoff, Han, Storr, Lerner, Johantgen and Gartrell53} Qualitative studies of CNAs identified several factors associated with decreased “intent to leave”: satisfaction with wages, benefits, and advancement opportunities and having a respectful nursing supervisor who was willing to help when needed. ^{Reference Bishop, Weinberg, Leutz, Dossa, Pfefferle and Zincavage54} Temple and colleagues found that involvement in resident care planning decreases the odds of high CNA turnover. ^{Reference Temple, Dobbs and Andel55}

Establishing processes for succession planning and cross-training HCP on IPC activities are also important for the continuity of the IPC program. Steps to mitigate the effects of high turnover on IPC practices include planning for continuous, ongoing educational efforts. ^{Reference Krein, Harrod, Collier, Davis, Rolle and Fowler56} Simple, regularly updated procedural documents that walk nursing home HCP through the steps of specific care activities (e.g., tracheostomy suctioning) can help decrease variability of practice. ^{Reference Katz, Osei, Vignesh, Montalvo, Oresanwo and Gurses57}

Internal working partners

5. How should the nursing home’s IPC program engage with facilities management?

Recommendation: To proactively manage potential IPC concerns, particularly as they relate to water management, airflow, air filtration, air disinfection, and construction, the IPC program should provide expert input and/or consultation to the facility management team, which may include a facility engineer, maintenance director, and/or industrial hygienist.

Rationale: The IPC program should develop a close working relationship with its facilities management team to ensure building systems are maintained and optimally functioning, and support collaborative responses to unexpected events, such as broken equipment or a leak in a roof. The IPC program should also be engaged by facilities management during the planning and execution of any construction projects. At a minimum, the IPC program should work with facility management to be familiar with water management and HVAC systems.

Water. The primary concern regarding water systems is the potential for waterborne pathogens, such as Legionella spp. and Elizabethkingia spp., which can colonize water environments and, through aerosolization, aspiration, or direct contamination, cause respiratory infections. ^{Reference Gettler, Smith and Lewis66} Water systems such as taps, aerators, drains, and faucets also can be a reservoir for other pathogens, including MDROs. ^{Reference Gettler, Smith and Lewis66,Reference Carling67} CDC, based on data from 15 acute and 57 long-term care settings, estimated a case fatality rate of 25% for definite and 10% for possible healthcare-associated Legionnaires’ disease. ^{Reference Soda, Barskey, Shah, Schrag, Whitney and Arduino68} The facility management team, including the maintenance department, and the IP should develop a water management program ⁶⁹ that ensures water quality and safety. The water management plan should include active monitoring of water systems through visual inspection of water tanks, pipes, sinks, hoppers, and equipment, and routine monitoring of temperature and disinfectant levels in premise plumbing (including wastewater plumbing) to support a safe water supply that is inhospitable to pathogens while avoiding the risk of burns to residents.

Airflow and ventilation. Respiratory outbreaks in congregate care settings can be caused by multiple organisms, but mainly viral respiratory pathogens including influenza, respiratory syncytial virus (RSV), human metapneumovirus, adenovirus, parainfluenza, and SARS-CoV-2. Proper ventilation is critical to efforts to prevent the spread of these viruses and others, including more rarely, varicella-zoster virus, which can cause shingles. The IPC program should play a role in enhancing and maintaining building air quality (see 28). For example, when building a new nursing home or an extension to an existing facility, IPC should be involved in considering whether to install a ventilation system that allows for negative pressure to be maintained in certain rooms when needed. ⁷⁰

Construction. Nursing homes are required to maintain a “safe, sanitary, and comfortable environment.” ¹⁸ The IPC program’s involvement in construction is well understood in acute care but may be less established in nursing homes. Especially during the COVID-19 pandemic, evidence emerged about the increased infection risk of aging infrastructure. ^{36,Reference Konetzka, Grabowski and Mor71} With calls for renovations and improvements to nursing home design, there is an increased need for the IP to coordinate with and provide input to facilities management to prevent potential construction-related infections.

External working partners

Consultants

6. What should nursing homes consider when deciding whether to hire an infectious disease or IP consultant?

Recommendation: Nursing homes may consider hiring external infectious diseases or IP consultants if the IPC risk assessment (see 4) reveals resident-level risk factors or process-level practice implementation gaps that require additional expertise.

Rationale: CMS requires that nursing homes conduct a facility-wide assessment at least annually to determine what IPC resources are necessary to provide safe care for its residents during both day-to-day operations and emergencies. This assessment considers the probability of infections based on the resident population, risk of IPC practice gaps based on personnel competencies and expertise, and facility resources. Although IPs have received specialized training, persistent turnover can compromise their operational experience. The facility assessment and gap analysis should consider the experience and expertise of current personnel involved in IPC programs. A 2015 survey indicated that IPs in nonacute care settings, including nursing homes, had limited experience in IPC; only 9% were certified in infection control. ^{Reference Pogorzelska-Maziarz and Kalp28} Clinical experiences of infectious disease and IP consultants can support IPC efforts. External consultants may help less experienced IPs conduct their facility assessment and suggest specific programs to address the identified needs, such as hand hygiene monitoring or standardized protocols to help decrease the use of urinary catheters.

In evaluations of whether to engage external infectious diseases or IP consultants, other considerations include the availability of relevant IPC data to inform areas for program improvement, internal expertise for data analyses, desired outcomes and goals for the program, available methods for sharing information securely with consultants, the medical complexity of nursing home residents, and the financial resources available to the facility. Defining the goals and resources for working with an external consultant will inform decisions about the specific services (e.g., in-person versus remote consultations; day-to-day engagement or periodic reviews; program development with or without subsequent maintenance) and resources needed (e.g., access to electronic health records; video equipment and communication systems compliant with the Health Insurance Portability and Accountability Act; support around licensure, contracting, and billing procedures).

The nursing home can also obtain support through collaborations with experts from the local community, hospitals within their referral network, and state/local public health programs (see 9). Such partnerships may be mutually beneficial with shared goals and logistical advantages (e.g., avoiding hospital readmissions, having decreased prevalence of MDROs and Clostridioides difficile [C. difficile] infections across institutions, having onsite consultations and opportunities for in-person education). ^{Reference Kullar, Yang, Grein and Murthy72}

7. How should the IPC program engage with the hiring and responsibilities of contract services?

Recommendation: Nursing homes should involve the IPC program in:

1. 1. Identifying IPC risks related to the proposed services (e.g., wound care, podiatry)

2. 2. Participating in hiring considerations and defining contractors’ responsibilities

3. 3. Educating contractors about IPC policies and protocols

4. 4. Monitoring contracted services’ compliance with IPC protocols.

Rationale: Lapses in IPC practices by contractors, such as inadequate cleaning and disinfection of shared equipment, have led to transmission of infections within nursing homes. Wise and colleagues described a hepatitis B virus outbreak affecting 5 of 15 residents who received podiatric care in a single day. ^{Reference Wise, Marquez, Sharapov, Hathaway, Katz and Tolan73} A hepatitis C virus outbreak involving 45 residents was found to be related to contracted podiatry and phlebotomy services. ^{Reference Calles, Collier, Khudyakov, Mixson-Hayden, VanderBusch and Weninger74}

The IPC program should always be involved with decisions to hire contractors to evaluate whether the proposed contracted services may increase infection transmission risks within the facility and, if yes, whether contractors have an adequate plan in place to mitigate those risks. Additionally, the IPC program should develop training for contractors on the facility-specific policies and protocols that should be followed while working at the facility. These include general principles related to Standard Precautions (e.g., hand hygiene, respiratory hygiene) and Transmission-Based Precautions, including, when appropriate, targeted education around donning and doffing PPE, wearing masks appropriately, and other activities relevant to a particular service.

Nursing homes should make sure that contractors who provide services that require equipment reprocessing (e.g., podiatry, dental, wound care services) are performing sterilization and disinfection per the equipment or device manufacturer’s instructions for use (MIFU) and are maintaining records. Preferably, the contractors should bring an adequate supply of clean and disinfected or sterilized instruments to provide safe care for all residents requiring the services.

The nursing home facility should make sure that contractors have appropriate space available in the building to provide the medical services safely. The treatment area should also have adequate supplies and access to PPE and ABHS. Steps should be in place to make sure that separation is maintained between clean and soiled equipment to prevent cross contamination. When possible, single-use, disposable equipment should be used, with a process in place for proper disposal after use. If a contractor uses reusable medical equipment to provide services, then processes should be in place for safe preparation and transport of the equipment for appropriate processing before use on anyone else. Finally, the IPC program should perform periodic audits to ensure compliance with the facility’s protocols related to the contracted services and provide appropriate feedback.

8. How should nursing homes verify IPC training and vaccination status for contract employees and consultants?

Recommendation: Nursing homes should ensure that the contract and onboarding processes for all contract employees and consultants include provisions requiring appropriate documentation of IPC training and vaccination status.

Rationale: Contract employees and consultants should follow the same IPC training and occupational health vaccination requirements that are applied to HCP who are directly hired by the nursing home. This expectation should be made clear at the time of contract negotiations and included in the contract itself. The contract should also include the provision for a contractor to share appropriate documentation verifying training and vaccination status for employees. If the contractor assumes responsibility for ensuring compliance with the facility vaccination requirements for employees, the contract should clearly state that appropriate documentation verifying the vaccination status of the contract employees will be shared with the nursing home. Similarly, if the contractor provides IPC training to employees, the IPC program may need to perform an assessment to ensure that the training meets the nursing home’s requirements before acceptance. Even if the specific training is acceptable, the nursing home should provide contract employees with additional orientation and education on facility-specific IPC protocols (e.g., the use of signage in the facility for Transmission-Based Precautions, proper use of facility-approved disinfectants including contact time). The nursing home’s IPC program should develop an internal process to keep track of IPC training and vaccination status of all the contract employees and to follow up with the contractors if any information is missing.

9. What relationship should nursing homes have with local and state public health departments?

Recommendation: Nursing homes should:

1. 1. Develop a relationship with local/regional and state public health departments for support, guidance, and collaboration with HCP within the local and regional healthcare continuum.

2. 2. Comply with reporting of cases and outbreaks of infectious diseases as required by local and state public health departments and institutional jurisdictions. Public health departments can help facilities in their efforts to prevent and control pathogen transmission.

3. 3. Partner with public health departments, local hospitals, and other healthcare organizations in quality improvement and safety collaboratives to support antimicrobial stewardship, to prevent infections, outbreaks, and the spread of MDROs, and to improve resident outcomes.

Rationale: State and local public health departments assist nursing home IPs in myriad ways by providing education, resources, and support for the implementation of IPC program activities. Public health department programs focused on prevention of HAIs and spread of antibiotic resistance have created online and in-person IPC trainings, templates, and tools to support infection surveillance, outbreak response, and antimicrobial stewardship and have provided remote and onsite technical assistance for the nursing home IP. ^{75–Reference Sloane, Zimmerman, Ward, Kistler, Paone and Weber79} An evaluation of the effect of various IPC activities led by state public health departments found that nursing homes in states offering IPC training for providers had fewer IPC-related deficiency citations. ^{Reference Cohen, Herzig, Carter, Pogorzelska-Maziarz, Larson and Stone80}

A relationship between a nursing home IP and the local public health department can improve communication and information sharing when the IP identifies questions related to IPC practices or reports a suspected outbreak to the appropriate public health authority in the region. When nursing homes report infection outbreaks, public health department staff can support nursing homes with collection of case data and interpretation of findings, including patterns of infections, laboratory results, observed symptoms, and surveillance definitions, and can offer strategies to disrupt ongoing transmission. Public health department programs can also facilitate opportunities for nursing homes to collaborate with community partners, including local hospitals and quality improvement organizations, to improve resident care and outcomes. ^{Reference Kullar, Yang, Grein and Murthy72,Reference Felsen, Dodds Ashley, Barney, Nelson, Nicholas and Yang81}

Members of the nursing home’s IPC program should have a clear understanding of the structure of their local and state public health jurisdictions to access support. Each jurisdiction may have a different reporting structure. Many corporate nursing home structures cross multiple state and local jurisdictions, meaning that corporate guidance may not pertain to local or regional public health requirements.

10. What IPC-specific information should be communicated during resident/patient transfers?

Recommendation: Nursing home HCP involved in resident transfers to or from hospitals, emergency departments, and primary care settings should be proficient in communicating and receiving IPC-specific information, including the resident/patient’s:

1. 1. History of colonization or infection with MDROs

2. 2. Relevant microbiological data, including cultures and susceptibilities

3. 3. Pending test results

4. 4. The need for and type of Transmission-Based Precautions

5. 5. The presence of indwelling medical devices, wounds, diarrhea, or uncontained secretions

6. 6. Current skin conditions

7. 7. Recent or current antimicrobial exposure

8. 8. Vaccination status for relevant vaccines (e.g., influenza, pneumococcus, COVID-19).

Rationale: The goal of a successful interfacility transfer is to ensure a safe handoff for a patient/resident moving from one healthcare facility to another as the care needs change. Having relevant information about risk factors and history of infection or colonization with germs that spread from person to person will ensure a safe environment for both the individual moving to a new care setting and the HCP receiving them.

Structured, systematic, and bidirectional communication around transitions of care is essential to patient safety. Ideally, communication about residents/patients as they transfer between healthcare institutions should occur among HCP with similar roles (i.e., nurses, pharmacists, and physicians). With the increasing focus on regional integration of healthcare systems, the nursing home may want to coordinate with their key referral hospitals to implement bidirectional, interfacility communication activities. ^{Reference Trick, Lin, Cheng-Leidig, Driscoll, Tang and Gao42,Reference Ponnada, Guerrero, Jury, Nerandzic, Cadnum and Alam82} Among resources available to support IPC programs in healthcare, CDC has an example of an interfacility transfer form that can be used to communicate IPC information. ^83,84

Barriers to vaccination

There is large body of evidence detailing barriers that may deter HCP from getting vaccinated. Nursing homes should implement and evaluate programs that address misconceptions about vaccination, especially in areas with low vaccine uptake. ^{Reference Huhtinen, Quinn, Hess, Najjar and Gupta96} Education and in-services can be rolled out using brief unscheduled sessions. In one study, 15-minute chance encounters and unplanned in-services helped deliver the message of importance of influenza vaccination and led to an increase in vaccine uptake. This principle can apply to other proven measures, such as hand hygiene and PPE use. ^{Reference Butteri, Radu, Huq, Wiglesworth, Durso and Bellantoni97}

Nace and colleagues reported that turnover of HCP was a barrier to vaccination uptake. ^{Reference Nace, Perera, Handler, Muder and Hoffman98} Kenny and colleagues found lack of encouragement from peers and failing to perceive the vaccination as rewarding were significant predictors of HCPs not intending to get vaccinated. ^{Reference Kenny, MNamara, Noone and Byrne99} Using US cross-sectional survey data, Groenewold and colleagues found that not feeling respected/rewarded for work was negatively associated with vaccination. ^{Reference Groenewold, Baron, Tak and Allred100}

In Michigan, Kimmins and colleagues found misconceptions or lack of knowledge were the most frequently cited barriers to vaccinations. ^{Reference Kimmins, Bramer, Chandler and Hart101} In a cross-sectional study in Tuscany, however, Domnich and colleagues found that confidence in vaccination was the strongest predictor of uptake and that health literacy was not a predictor. ^{Reference Domnich, Cambiaggi, Vasco, Maraniello, Ansaldi and Baldo102} Lorini and colleagues found that people’s perceptions of risk versus value and the norms of their social groups affected vaccine uptake. ^{Reference Lorini, Ierardi, Gatteschi, Galletti, Collini and Peracca103}

Interventions to increase uptake

Numerous researchers have reported that interventions that are tailored and multifaceted improve vaccine uptake. In 2010, Lam and colleagues published a systematic review of 12 eligible studies investigating campaigns to improve HCP vaccination in nonhospital settings, including nursing homes, and found that campaigns with a greater variety of components (e.g., education, better access, role models, legislation or regulation) were the most effective. ^{Reference Lam, Chambers, MacDougall and McCarthy104} Ofstead and colleagues tested customized multifaceted interventions in four facilities in the Midwest and found HCP vaccination uptake increased from 50% to 85% (p < 0.01) and absenteeism due to respiratory illness decreased from 31% to 19% (p < 0.01) in the year after the intervention. ^{Reference Ofstead, Amelang, Wetzler and Tan105} Looijmans-van den Akker and colleagues conducted a cluster randomized controlled trial in 33 Dutch nursing homes to assess the effects of a systematically developed multifaceted intervention program to improve influenza vaccination uptake in HCP. ^{Reference Looijmans-van den Akker, van Delden, Verheij, van der Sande, van Essen and Riphagen-Dalhuisen106} The program, which included vaccine promotional materials (e.g., posters), education and personalized communication (letters to HCP), hosting informational meetings to address HCP questions, and identifying vaccine role models, produced significantly higher vaccination rates, but uptake remained moderate. Using materials designed to facilitate the implementation of similar interventions, additional studies found comparable results. ^{Reference Boey, Roelants and Vandermeulen107,Reference Chambers, Crowe, Lam, MacDougall, McNeil and Roth108} In July 2021, CMS-certified nursing homes reported 82.3% of residents and 60.8% of HCP had been fully vaccinated against COVID-19 (84.8% of residents and 62.6% of HCP had been partially vaccinated). ^{Reference Geller, Budnitz, Dubendris, Gharpure, Soe and Wu109} The authors concluded that facilities should use communication resources developed to increase vaccine confidence among HCP and strategies to address structural barriers, such as scheduling or paid medical leave for possible postvaccination side effects.

Black and colleagues found that influenza vaccination coverage was highest (94.8%) among HCP in settings where vaccination was required, although during the 2017-2018 influenza season, only 29.6% of nursing home HCP reported their facilities having a vaccination requirement. ^{Reference Black, Yue, Ball, Fink, de Perio and Laney110} The study also found that influenza vaccination coverage was lowest for nursing assistants and aides in nursing homes compared with other HCP. In France, Elias and colleagues found that better knowledge about influenza prevention tools was correlated (p < 0.001) with higher influenza vaccination coverage in HCP. Individual perceptions of vaccination benefits also had a significant influence on the coverage (p < 0.001). ^{Reference Elias, Fournier, Vasiliu, Beix, Demillac and Tillaut111} Similar findings were reported among nursing home HCP in Ireland. ^{Reference Kenny, MNamara, Noone and Byrne99}

Priorities for routine surveillance

A primary goal for nursing home IPC programs is to improve resident care through the prevention of pathogen spread and reduction of HAIs. To accomplish this, the IP in conjunction with the QAA committee should have a written surveillance plan outlining which HAIs will be routinely monitored and reported for quality improvement and/or regulatory purposes. HAI surveillance is used to set goals for the IPC program’s prevention activities and should be reassessed on at least an annual basis.

Selecting HAIs to include in the surveillance plan may involve several strategies, including identification of specific pathogens (e.g., C. difficile), antimicrobial resistance patterns (e.g., carbapenem-resistant), and clinical syndromes consistent with transmissible infections (e.g., influenza-like illness or gastroenteritis). The IPC risk assessment can inform the HAI surveillance plan based on specific resident populations, device use, and antibiotic use.

Facilities should prioritize HAIs that link to IPC prevention goals that can be reliably assessed and achieved (e.g., improving central line accessing and dressing care to reduce central line-associated bloodstream infection [CLABSI]). A routine surveillance plan should address transmissible, preventable infections with high morbidity, mortality, or impact on the quality of life for residents. ^{Reference Stone, Ashraf, Calder, Crnich, Crossley and Drinka112}

The US Department of Health and Human Services (HHS) Long-Term Care Facility National Action Plan identified several infection surveillance and prevention targets for nursing home IPC programs, including laboratory-confirmed C. difficile, urinary catheter use, catheter-associated urinary tract infections (CAUTIs), pneumococcal and influenza vaccination rates in residents, influenza vaccination rates in HCP, and antimicrobial stewardship. ^48,113 The CDC National Healthcare Safety Network (NHSN) is a web-based surveillance platform available to nursing homes that can support tracking of HHS priorities through modules for healthcare-associated UTI, laboratory-based identification for MDRO and C. difficile infection, and preventative process modules. ^{Reference Palms, Mungai, Eure, Anttila, Thompson and Dudeck114} NHSN provides nursing home-specific training, tool kits, and a web-based platform to help facilities identify HAIs in a standardized fashion. ¹¹⁵ However, the IP needs dedicated time to understand and implement NHSN reporting processes and leadership support to maintain access to the NHSN system (e.g., serve as a NHSN user for the facility). During the COVID-19 pandemic, CMS required nursing homes to report COVID-19 data of residents and HCP and COVID-19 vaccination rates into NHSN. ¹¹⁶

Standardized definitions and methods for surveillance

An effective surveillance program must have accurate, standardized, and reproducible methods to detect infections that minimize subjective interpretation and interobserver variability over time. The McGeer infection surveillance definitions for long-term care facilities, originally developed in 1991 and revised in 2012, provide a standard set of criteria designed for nursing home surveillance activities. ^{Reference Stone, Ashraf, Calder, Crnich, Crossley and Drinka112,Reference Rowe, Jump, Andersen, Banach, Bryant and Doernberg117} Retrospective identification of infections is typically accomplished through the review of residents’ medical records, discharge summaries, laboratory and radiology reports, and medication and treatment records. Electronic access to health records is ideal. Each defined HAI should be recorded using standardized methods, such as line listings, and reported by the number of HAIs and rates of each HAI per 1000 resident-days. ^{Reference Stone, Ashraf, Calder, Crnich, Crossley and Drinka112,Reference Bradley, Weber and Talbot118,Reference Han, Stone, Lautenbach, Malani, Woeltje, Han, Shuman and Marschall119}

Although all CMS-certified nursing homes have been required to track a resident’s admission, and on a quarterly basis information about UTIs, pneumonias, C. difficile, and antibiotic-resistant bacteria using the Minimum Data Set, Minimum Data Set definitions are not the same as those used for HAI surveillance and should not be substituted for infection surveillance purposes. ^{Reference Herzig, Dick, Sorbero, Pogorzelska-Maziarz, Cohen and Larson30}

Implementation of IPC practices

Implementing evidence-based practices and recommendations can be challenging, particularly in nursing homes, which may have limited resources and HCP and residents who have high acuity of care. In this section, implementation strategies that have been studied and found to help implement IPC evidence to practice are described.

Commonly audited practices

17. What should a nursing home’s hand hygiene program include?

Recommendation: A nursing home’s hand hygiene program should include:

1. 1. Interactive, regular education with demonstrations of technique, auditing, feedback, and access to educational materials

2. 2. Active engagement by the nursing home’s leadership, clinical HCP, and nonclinical HCP in the practice and promotion of hand hygiene

3. 3. Easy access to ABHS (see 23).

Rationale: Proper hand hygiene is the basic tenet of IPC. However, hand hygiene adherence remains a challenge. In one study, hand hygiene adherence occurred in 96 of 352 observations before resident care (27.3%) and only 165 of 358 observations after resident care (46.1%). ^{Reference Mills, Zhu, Mantey, Hatt, Patel and Kaye143} Some of the factors influencing adherence include HCP time constraints, availability of hand sanitizers at point of care, and competing priorities.

Several studies have shown that hand hygiene programs are effective, efficient, and reduce infections as well as antimicrobial-resistant organisms. ^{Reference Huang and Wu144,Reference Mody, McNeil, Sun, Bradley and Kauffman145} Ensuring HCP understand how to incorporate hand hygiene into resident care activities based on type of care delivered and length of time spent with a resident can reinforce the importance of adherence. Hand hygiene programs that involved distribution of pocket-sized hand sanitizers and educational materials were effective in enhancing hand hygiene and reducing infection rates. ^{Reference Koo, McNamara, Lansing, Olmsted, Rye and Fitzgerald146–Reference Yeung, Tam and Wong148} Tailoring hand hygiene products to local preferences can enhance engagement and improve compliance with key hand hygiene measures. ^{Reference Forrester, Bryce and Mediaa135,Reference Glowicz, Landon, Sickbert Bennett, Aiello, deKay and Hoffmann136} Studies have shown that multicomponent interventions that include performance feedback after the first evaluation phase, several training sessions, assessment of hand hygiene technique, a full day of hand hygiene training, and focusing on institutional communication can improve hand hygiene rates. Furthermore, education and awareness of institutional policies can enhance hand hygiene, particularly in high-risk activities. ^{Reference Montoya, Chen, Galecki, McNamara, Lansing and Mody149} HCP engagement is important in deciding the best two or three interventions to improve hand hygiene compliance. ^{Reference Teesing, Erasmus, Petrignani, Koopmans, de Graaf and Vos150} Informed by local challenges and cultures, a combination of these strategies should be used to improve hand hygiene.

Auditing HCP adherence to hand hygiene during resident care activities may be conducted in various ways. ^{Reference Forrester, Bryce and Mediaa135,Reference Glowicz, Landon, Sickbert Bennett, Aiello, deKay and Hoffmann136} Nursing home HCP can be trained to serve as secret observers on units as part of their routine activities. Residents and visitors might volunteer to observe HCP hand hygiene practices. ¹⁵¹ Some healthcare facilities have incorporated use of automated or electronic hand hygiene monitoring systems into units to capture more data than observations might be able to generate. ^{Reference Iversen, Hansen, Munster, Kristensen and Ellermann-Eriksen152,Reference Starrett, Arbogast, Parker, Wagner, Mahrer and Christian153}

18. How should nursing homes assess HCP knowledge and skill in device insertion, maintenance, and removal?

Recommendation:

1. 1. HCP should be knowledgeable about medical devices (e.g., central lines, indwelling urinary catheters, percutaneous gastrostomy tubes, tracheostomy tubes) including:

   1. a. The risks associated with their use

   2. b. Recommended IPC practices during placement, maintenance, and removal.

2. 2. Nursing homes should document:

   1. a. The presence, indication for, and duration of a medical device

   2. b. Regular assessment of the ongoing need for a device, presence of signs or symptoms of infection or device malfunction, and opportunities for early and prompt removal

   3. c. Adherence to the recommended steps during insertion, maintenance, and removal of the medical device

3. 3. Nursing homes may conduct audits using standardized forms or forms tailored to the needs and processes of the nursing home.

Rationale: A bundled approach to implementing safe device use and maintenance has been shown to successfully reduce device-related infections like CAUTI and CLABSI in nursing homes. In a cluster-randomized clinical trial at 12 community-based nursing facilities focused on high-risk residents with indwelling urinary catheters, a multimodal targeted infection program reduced the prevalence of MDROs by 23% and the incidence of device-related infections by 45%. The interventions included preemptive barrier precautions during care of residents with indwelling devices, active surveillance for MDROs and infections, and HCP education. In addition, the multicomponent intervention improved IPC knowledge in HCP and was expected to benefit payors by reducing costs and improving health outcomes. ^{Reference Mody, Krein, Saint, Min, Montoya and Lansing137} Similarly, a multimodal approach successfully reduced adverse events and infections in other types of devices, such as gastric tubes and tracheostomies. ^{Reference Gavi, Hensley, Cervo, Nicastri and Fields154}

In a study that evaluated the effect of implementing IPC bundled practices focused on medical device care and handling, using a multidisciplinary, collaborative approach, CAUTIs were reduced by 50% and CLABSIs by 25%. ^{Reference Clifton, Kralovic, Simbartl, Minor, Hasselbeck and Martin155} The program focused device insertion technique, reviewing the indication and ongoing need of the device, and audited specific practices for each device. Among residents who have central lines, the bundle assessment included changing the dressing, tubing, and needleless connectors; verifying that dressings are clean, dry, and intact; and scrubbing the hub before accessing the line. ^{Reference O’Grady, Alexander, Burns, Dellinger, Garland and Heard156} In residents with indwelling urinary catheters, the bundle assessments included addressing functioning (e.g., unobstructed flow) and handling during care (e.g., collection bag below the bladder, proper technique when accessing for specimen collection). ^{Reference Gould, Umscheid, Agarwal, Kuntz and Peques157} Tools and checklists that can support the implementation and assessment of device-associated prevention bundles are available. ^158,159

19. How should nursing homes conduct environmental cleaning and disinfection?

Recommendation: Nursing homes should:

1. 1. Have clearly written policies on the processes and time involved in cleaning and disinfection of environmental surfaces in shared areas, residents’ rooms, and for reusable medical equipment

2. 2. Ensure that written policies address the frequency of both routine cleaning and disinfection practices, and cleaning and disinfection practices during outbreak situations (see 30)

3. 3. Audit practices for equipment and areas that are cleaned and disinfected, such as frequency and adequacy of cleaning and adherence to contact time (how long a disinfectant remains wet on a surface)

4. 4. Assess availability of appropriate cleaning and disinfection supplies at the point of care, ensuring that products are EPA-registered as effective for the purpose for which they are being used (see 31)

5. 5. Use objective methods for evaluation of routine environmental cleaning, which may include direct observation, fluorescent markers, or adenosine triphosphate (ATP) bioluminescence

6. 6. Focus on HCP education and training and provide regular performance feedback.

Rationale: Environmental contamination is a risk factor for transmission of pathogens. Multiple studies have demonstrated the presence of clinically significant pathogens on items and high-touch surfaces in residents’ rooms and common areas. ^{Reference Thompson and Schaefer160–Reference O’Fallon, Schreiber, Kandel and D’Agata165} One study used a nonpathogenic deoxyribonucleic acid (DNA) marker inoculation onto the television remote controls in rooms of two ambulatory long-term care facility residents and demonstrated dissemination of the DNA marker to the hands of nursing home residents, high-touch surfaces in the room, on the ward, and to shared portable equipment, indicating the importance of cleaning of surfaces frequently touched by residents. ^{Reference Bradwell, Johnson, Lee, Winnington, Thill and Jones161–Reference Kovach, Taneli, Neiman, Dyer, Arzaga and Kelber163,Reference O’Fallon, Schreiber, Kandel and D’Agata165,Reference Alhmidi, Koganti, Cadnum, Jencson, John and Donskey166} Studies showed that environmental contamination often depends on frequency and time spent in the cleaning of individual resident rooms and common areas, as well as overall prevalence of organisms in nursing facilities. Proper cleaning and disinfection have been demonstrated to reduce microbial burden. ^{Reference Bradwell, Johnson, Lee, Winnington, Thill and Jones161–Reference Kovach, Taneli, Neiman, Dyer, Arzaga and Kelber163}

Audits of reusable medical device use and reprocessing have also revealed issues in IPC. One study found that HCP in two skilled nursing facilities were incorrectly using blood glucose monitoring equipment, leading to six hepatitis B cases. ^{Reference Sena, Moorman, Njord, Williams, Colborn and Khudyakov167} These outbreaks highlight the need to use audits specifically to address adherence to evidence-based IPC practices by HCP. ^{Reference Reynolds168} Facilities may also evaluate whether there are technological advances (e.g., single-use glucose monitoring devices) that could reduce transmission risk. ^{Reference Thompson and Schaefer160}

Cleaning supplies should be readily available and easily accessible. Facilities should use disinfectants approved for use against the pathogen of interest. The most commonly used method for assessing the adequacy of environmental cleaning in nursing homes is visual assessment performed by the supervisor for randomly selected rooms. ^{Reference Saeb, Mody and Gibson169} This method to evaluate cleanliness may identify visible soilage but has poor correlation with identification of microbial contamination and is subject to high potential for observer bias. ^{Reference Carling and Bartley170} A study comparing use of visual inspection, performance observation, and ATP interpretation found the results to be inconsistent, with weak positive correlation between visual inspection and performance observation but no correlation between visual inspection and ATP interpretation. ^{Reference Chen, Huang, Lin and Shi171} CMS has recommended that nursing homes use objective methods for evaluation of routine environmental cleaning, including direct practice observation, fluorescent markers, or ATP bioluminescence. ¹⁷²

Studies evaluating the effectiveness of different methods for assessing adequacy of environmental cleaning have predominantly been in acute-care settings. ^{Reference Carling and Bartley170,Reference Chen, Huang, Lin and Shi171,Reference Burnham, Shives, Warren, Han, Babcock and Program173} The results of these studies support combining routine objective assessments with HCP education and performance feedback for improvement in environmental cleaning. ^{Reference Carling and Bartley170} However, currently inadequate evidence exists to make a preferential recommendation for the best objective assessment methods to use in the nursing home setting. Rather, nursing homes should choose among objective measures that include regular HCP education and performance feedback for their environmental cleaning and disinfection program, based on available resources.

20. How should nursing homes ensure proper use of PPE?

Recommendation: Nursing homes should:

1. 1. Develop a written policy for Standard and Transmission-Based Precautions that describes the types of PPE, indications for use, and proper steps for donning (putting on) and doffing (removing) the PPE

2. 2. Provide HCP with ready access to PPE, including gowns, gloves, eye protection, surgical masks, and respirators

3. 3. Ensure HCP select and use PPE based on the nature of the resident interaction and the potential for exposure to blood, body fluids, or infectious material

4. 4. Monitor adherence to practices and provide feedback (see 22)

5. 5. Make PPE available at the point-of-care when residents are placed on Transmission-Based Precautions.

Rationale: Standard Precautions are the basic practices that apply to all individuals in settings where healthcare is delivered, regardless of a person’s suspected or confirmed infectious state. ¹⁷⁴ Standard Precautions protect HCP and prevent HCP or the environment from transmitting pathogens to others. Appropriate selection and use of PPE are essential elements of Standard Precautions and based on the type of interaction and exposure anticipated when providing care. Examples of PPE selection as part of Standard Precaution include wearing gloves when contact with blood or other body fluids, mucous membranes, or non-intact skin could occur; wearing gowns during procedures and activities that can lead to splashes of blood, body fluids, or other secretions; and using protective eyewear and mask or face shield to protect eyes, nose, and mouth during procedures and activities that could generate splashes of blood, body fluids, and secretions.

Transmission-Based Precautions are applied when Standard Precautions alone may not be sufficient to prevent pathogen transmission. The type of Transmission-Based Precautions used are based on the known or suspected routes by which an infectious pathogen can spread. For example, Contact Precautions, which includes use of gowns and gloves during care interactions, are used to disrupt the spread of pathogens by direct or indirect contact with a resident or their environment. When used either singly or in combination, they are always used in addition to Standard Precautions.

Although the use of gowns and gloves has been shown to reduce transmission of pathogens, ^{Reference Lydecker, Osei, Pineles, Johnson, Meisel and Stine175} their use in nursing homes, especially gowns, remains suboptimal. When nursing homes have PPE readily available, use by HCP and adherence to precautions are increased. Gowns stored in supply closets, for example, are rarely used. Along with interactive education and leadership buy-in, making PPE available at the point of care increases adherence and reduces colonization pressure and infections among high-risk residents. ^{Reference Mody, Krein, Saint, Min, Montoya and Lansing137,176}

21. What should nursing homes’ vaccination policies include?

Recommendation: Nursing homes should have written, up-to-date policies for vaccination of residents and HCP that include education, training, and monitoring of vaccination acceptance rates.

Rationale: A vital component of the IPC program is promoting vaccination to residents and HCP against respiratory viruses and other vaccine-preventable infections to prevent introduction and spread of these pathogens in nursing homes. Facility policies and procedures should address when vaccines are offered, how to promote vaccine acceptance, how to transport and store the vaccines properly, how to administer them safely, and how to maintain documentation of resident and staff vaccination status. Strategies to increase staff vaccination acceptance, including promoting the benefits of vaccine, providing educational materials, and having conversations to address questions and misconceptions, (see 12), are also important when discussing vaccines with HCP, residents, and families. ^{Reference Gadbois, Meehan, Uth, Baier, Gravenstein and Zullo177}

Evidence-based tools, such as those developed by AHRQ, can support nursing home efforts to monitor vaccination acceptance rates of residents and HCP, coordinate next doses, and identify vaccine hesitancy. ¹⁷⁸ These resources enable nursing homes to track and trend vaccine administration data (e.g., COVID-19, influenza) for both residents and HCP and assist with compiling accurate data for reporting to the CDC NHSN. ⁵⁹

22. What methods should nursing homes use to provide feedback on HCP adherence to IPC practices?

Recommendation:

1. 1. Nursing homes should use audit and feedback methods to improve and sustain compliance with evidence-based practices:

   1. a. For individual HCP, nursing homes should use specific, just-in-time feedback on the process being audited

   2. b. At the unit or facility-level, nursing homes should use simplified, aggregated data from audits during rounds, QAA meetings, personnel newsletters, and reporting huddles.

2. 2. Nursing homes should train HCP who conduct these audits to use standardized tools and definitions.

3. 3. Nursing homes should provide feedback to HCP on signs of potential lapses in IPC practices during care.

Rationale: Sustainable improvements in IPC require culture change, increased HCP involvement, explicit administrative support, and meaningful, timely feedback. Providing feedback to facility HCP about their adherence to IPC practices helps reinforce the importance of these activities and maintains awareness of the facility’s policies and procedures. Feedback also serves as a strategy to engage HCP and develop shared goals to reduce infections in nursing homes.

Nursing homes may share feedback in multiple ways. For example, performance monitoring data can be aggregated and summarized facility-wide or broken down by unit, shift, or provider type to compare differences in performance. Individualized feedback can be shared during one-on-one meetings with HCP or provided at the moment when the care activity is occurring or “just-in-time,” to provide a gentle reminder and immediate learning opportunity. Multimodal interventions that incorporate feedback of hand hygiene compliance with optional interventions have been successful (e.g., e-learning, kick-off workshop, observer training, team training). ^{Reference van Dijk, Mulder, Erasmus, van Beeck, Vermeeren and Liu179} In one study, investigators created a tool to measure the IPC practices such as hand hygiene compliance, environmental contamination, prevalence of MDROs using active surveillance approach, appropriate use of indwelling devices, and antibiotics. This led to the creation of a personalized facility-level spider plot that was then shared with respective facilities and led to standardization of implementation across sites, enhanced transparency, and improved outcomes. ^{Reference Willemsen and Kluytmans180}

Environmental cleaning and disinfection

30. How frequently should nursing homes clean and disinfect surfaces in residents’ rooms, shared bathrooms, and shared areas?

Recommendation: Although the optimal frequency of cleaning and disinfection of areas in nursing homes remains unclear, nursing homes should provide adequate time for HCP to:

1. 1. Routinely clean and disinfect resident rooms, shared bathrooms, and shared areas at least once a day, paying particular attention to high-touch surfaces with an EPA-registered disinfectant active against the pathogens most likely to contaminate the resident care environment

2. 2. Perform cleaning immediately upon noticing visibly soiled surfaces

3. 3. Increase the frequency of cleaning and disinfection during outbreaks.

Rationale: Cleaning and disinfection of resident rooms and shared areas are important in preventing transmission of pathogens within the nursing home. Limited studies have evaluated the optimal frequency of cleaning and disinfection of residents’ rooms and shared areas. CMS guidance calls for routine cleaning and disinfection of frequently touched or visibly soiled surfaces in common areas, residents’ rooms, and at time of discharge. ¹⁸ One prospective study of environmental contamination and cleaning quality found that, in addition to the high MRSA burden within the facility, spending less time during cleaning and/or less frequent cleaning of common rooms were significantly associated with MRSA environmental contamination. ^{Reference Murphy, Eells, Quan, Kim, Peterson and Miller164} The frequency of cleaning ranged from 1 to 3 times/day (median 2.5 time) within the 10 nursing homes that participated in that study.

Nursing homes should consider cleaning and disinfecting resident rooms, shared bathrooms, and shared areas at least once a day, especially focusing on high-touch surfaces. Because an increased microbial burden on environmental surfaces has been shown during outbreaks, ^{Reference Mody, Gibson, Mantey, Bautista, Montoya and Neeb199,Reference Wu, Fornek, Schwab, Chapin, Gibson and Schwab200} facilities should increase the frequency of cleaning and disinfection during outbreak response.

31. What are the cleaning and disinfection considerations for equipment shared among residents (e.g., shower chairs, blood pressure cuffs, mechanical lifts) and residents’ personal belongings?

Recommendation: Nursing homes should:

1. 1. At least daily, clean and disinfect residents’ frequently used items (e.g., canes, walkers, remotes, tablets, phones)

2. 2. After each use, clean and disinfect items that are shared among residents

3. 3. Choose products that are EPA-registered for the specific cleaning and disinfection purpose

4. 4. Follow the MIFU for equipment and the cleaning products used to avoid damaging existing equipment and objects

The laundry section (see 24) addresses cleaning of residents’ soft items, as appropriate. Care of residents’ personal hygiene items (e.g., toothbrushes) are outside the scope of this document.

Rationale: CMS guidance outlines the requirement for routine cleaning and disinfection of resident care equipment, including equipment shared among residents (e.g., blood pressure cuffs, rehabilitation therapy equipment, blood glucose meters). ¹⁸ To avoid transmission of pathogens among residents, nursing homes should clean and disinfect all items that are shared among residents after each use.

Studies have not evaluated the optimal frequency of cleaning residents’ personal belongings, but, for residents’ frequently used items (e.g., canes, walkers, remotes, tablets, phones) the same principles should apply as described above for high-touch surfaces in resident’s rooms (see 30). Nursing homes should clean, or when feasible, facilitate cleaning with residents or family members, frequently used personal items of residents at least once daily.

CDC guidelines for environmental IPC in healthcare facilities recommend following MIFUs for cleaning and disinfection of medical equipment. ²⁰¹ When MIFUs are not available, noncritical medical equipment (e.g., stethoscopes, blood pressure cuffs, equipment knobs and controls) usually only require cleaning and low- to intermediate-level disinfection depending on the nature and degree of contamination.

To facilitate timely cleaning and disinfection of these items, the cleaning and disinfection products should be available to HCP at the point of use. When choosing cleaning and disinfection products, nursing homes should use products that are EPA-registered for the specific cleaning and disinfection purpose. ²⁰² HCP and should follow the MIFU for selected cleaning products for instructions about material compatibility, dilution, contact time, storage, shelf-life, safe use, and disposal.