When COVID-19 Knocks on Nursing Homes’ Doors, Systemic Problems Welcome It

Despite nursing homes becoming a nidus of multi-drug resistant organisms (MDROs), the regulations for staffing infection preventionists (IPs) at nursing homes are far too lax. Nursing homes should have a full-time IP. Presently the regulations only specify a part-time IP without a specific required time commitment. In view of the large number of nursing home residents and the high drug-resistant carriage rate, a full-time position is certainly needed.¹

That’s especially true these days, as COVID-19 hits nursing homes with particularly devastating results. At the now-infamous Life Care Center, a 130-resident nursing home facility in King County, Washington, COVID-19 infected 81 residents, 34 staff and 14 visitors, causing 23 deaths (22 of them residents).² More recent updates place the total deaths at 35; 34 of whom were residents. As of March 23, 127 of the 15,000 nursing homes in the United States had at least 1 resident who tested positive for COVID-19.³

Mortality rates also increase with the presence of heart or chronic respiratory diseases, which are common in nursing homes and other long-term care facilities. Rates of chronic obstructive pulmonary disease are greater than 20%, and for heart disease they are greater than 30% in long-term care facilities. 

So, expect mortality from COVID-19 to be significantly higher at nursing homes and other long-term care environments than among the general population just as a function of advanced age and comorbidities of the residents. In China, the case fatality rate (CFR) is estimated to be 8.0% for those 70 to 79 years of age, and for patients over 80, that shoots up to 14.8%.⁴ Even as the CFR drops with improved treatment, it is expected that those over the age of 80 will have a 10 times higher fatality rate than younger patients.⁵

Many nursing homes around the nation have suspended all visitations, which hopefully will increase the awareness of the importance of controlling the microbiome in nursing homes. Most hospitals routinely screen patients admitted from nursing homes for MDROs, but nursing homes seldom engage in similar action.

Nurse staffing in nursing homes is also all too often inadequate, although state requirements may vary. The federal government relies on the requirement to have “sufficient nursing staff.” The definition of “sufficient” is largely in the eyes of the facility.⁶

In addition to low staffing, salaries for nursing home nurses are lower than they are at hospitals. According to payscale.com, the average RN and certified nursing assistant are paid $28 and $12 per hour, respectively, as those in hospitals are paid $29 and $13 per hour. Even at these salaries, coverage of living expenses can be difficult.

In terms of quality of care, none of the US Centers for Disease Control and Prevention’s 5 most “urgent threats”⁷ are mandated to be reported on a national basis by nursing homes. The only nationally reported data on infectious disease which can be found on Nursing Home Compare are for urinary tract infection. State requirements vary widely. Nursing homes need to have a comprehensive mandatorily reported national tracking system for infectious disease.

Even before the COVID-19 virus refocused the nation’s attention on nursing homes, there were severe deficiencies in infection control. A recent study in California found that over 50% of nursing home residents harbor MDROs.⁸ Of course, extrapolating this data to the entire nation needs to be done with caution, but California has one of the lowest rates of antibiotic usage in the nation.⁹ Some states in Appalachia, such as my home state of Kentucky, have over twice the utilization. At the very least, this study raises grave concerns.

Required antibiotic stewardship programs are all too often ineffective. The CDC estimates that up to 75% of antibiotics in nursing homes are not prescribed correctly.¹⁰ One study found that 42% of the residents in nursing homes are carriers for methicillin-resistant Staphylococcus aureus(MRSA) and 34% carry extended-spectrum β-lactamase-producing organisms.⁸Both of these organisms are defined as “serious threats” by the CDC. CMS tolerates a medication error rate of 1 in 20 prescriptions.¹¹ There are few requirements for antibiotic prescription oversight. The CDC recommends antibiotics administered for sepsis be rechecked by a professional within 48 to 72 hours after initiation. This standard should also be applied for all antibiotics given in nursing homes. A common failing is the unnecessary continuation of antibiotics in newly admitted residents, since a facility physician visit is not required for up to 30 days post admission and if requested, it is considered timely if it occurs within 10 days.¹²

In response to this threat, the US Centers for Medicare & Medicaid Services (CMS), in collaboration with the CDC, will be initiating targeted infection control inspections with streamlined checklists. During this time standard inspections of nursing homes will be suspended. However, the current CMS suspension of standard inspections indicates a temporary shifting of resources and unless a permanent commitment of new resources is made, there may well be a rapid return to the status quo.

The CDC has also attempted to strengthen regulations which give little if any firm guidance. The CDC has developed a program for nursing home infection prevention referred to as “enhanced barrier precautions.” Although the name implies strict infection control procedures, it may actually be recommending far too little to control the frequent occurrence of dangerous contagions in nursing homes. 

The premise behind the protection of healthcare workers and residents with enhanced barrier precautions is that some resident encounters have a higher risk of transmission of pathogens than others. And that contact precautions should be reserved for those encounters with the highest risk, thus, helping to preserve the patient’s dignity. However, recommendations need to be effective, since no nursing home resident wishes to preserve dignity by infecting visiting grandchildren with a dangerous contagion. 

Three of the organisms which are targeted for control with enhanced barrier precautions are contained on the CDC’s list of “urgent threats.” MRSA, another common nursing home pathogen, is also targeted and is on the CDC’s list of “severe threats.”

There are 2 concerns. The first is that although lower risk encounters carry a relatively low risk of transmission, some encounters, such as passing meds, occur so frequenty that the risk to the healthcare worker over time can be high. For example: The passing of meds to a MRSA carrier is defined as a low-risk activity. Each encounter was found by Roghman, et al., to contaminate healthcare workers’ gowns and gloves with MRSA 8% and 16% of the time, respectively.¹³ The study found a 25% MRSA carrier rate in nursing home residents and if one assumes a healthcare worker passes meds to 25 patients 3 times a day, they would be expected to contaminate their clothes 11 times a week.

Another study by Blanco, et al., evaluated the risk of contamination with gram negative bacillus.¹⁴ Using the same methodology, it can be predicted that the passing of meds would result in the contamination of a healthcare worker’s clothes once a week.

The second is that enhanced barrier precautions do not restrict the movements of a carrier within a facility, which is problematic. The CDC notes that environmental colonization with MDROs can last longer than 6 months.

In the case of MRSA, one study has found colonized patients contaminated the environment more frequently than those with an active infection.¹⁵ MRSA carrier contamination of the environment can occur very rapidly with 35% of carriers contaminating their environment within 33 hours¹⁶ and the contamination may last as long as 2.33 to 8.35 years.¹⁷

We need to start fostering an optimal patient microbiome, but the United States does not even adequately screen for MDROs. Staph aureus, for example, is a major cause of post-operative infections. The WHO recommends that in affluent countries, all patients undergoing surgery be screened and decolonized for Staph aureus.¹⁸ However, in the US we do not even do this for MRSA.

In nursing homes, we need to develop and implement a strategy based upon the existing microbiome of the facility and the compatibility with the resident’s microbiome. The average resident resides in a nursing home for over two years and determining the resident’s microbiome before admission should become standard. If the resident carries dangerous contagions, then decolonization should be attempted. Some organisms such as carbapenem-resistantEnterobacteriaceae (CRE) may have very long durations of colonization (over a year) and how to best decolonize is not known.¹⁹ In such cases, admission into a compatible facility or zone isolation should be implemented.

Finally, the health and wellbeing of infection preventionists along with all healthcare workers needs to be safeguarded. At a minimum, workers should be periodically screened for dangerous contagions and a national registry created for acquisitions. In addition, a healthcare worker’s economic safety net needs to be established. Decolonization of healthcare workers should be undertaken. For MRSA this has been found to have up to an 88% success rate.²⁰

There can be no doubt that COVID-19, along with other MDROs, pose unacceptable risks to nursing home residents, IPs and all healthcare workers, along with their families. Correction will require a sustained commitment to invest in infrastructure, new technologies and implement resource intense strategies. 

These pathogens are relentless, they are evolutionarily programed to win, and they are currently doing just that.

References:

(1)  (9)   42 CFR § 483.80 - Infection control. Cornell Law Scholl Legal Information Institute.   42 CFR § 483.30(b)    https://www.law.cornell.edu/cfr/text/42/483.80

(2) McMichael TM, et al. Centers for Disease Control and Prevention.   COVID-19 in a Long-Term Care Facility - King County, Washington, February 27–March 9, 2020.   MMWR / March 18, 2020 / Vol. 69   http://www.documentcloud.org/documents/6812675-CDC-Life-Care-Center-of-Kirkland.html
  
(3)  CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19    https://www.cms.gov/newsroom/press-releases/cms-announces-findings-kirkland-nursing-homeand-new-targeted-plan-healthcare-facility-inspections 
    
(4)  The Epidemiological Characteristics of an Outbreak of 2019 NovelCoronavirus Diseases (COVID-19) - China, 2020.   China CDC Weekly.    http://www.ne.jp/asahi/kishimoto/clinic/cash/COVID-19.pdf      
 
(5)  Dosa  D, Jump  RLP , LaPlante K, Stefan Gravenstein S.   Long-Term Care Facilities and the Coronavirus Epidemic: Practical Guidelines for a Population at Highest Risk.  J Am Med Dir Assoc,  2020 Mar 13[Online ahead of print]   https://www.jamda.com/article/S1525-8610(20)30249-8/fulltext  
  
(6)  42 CFR § 483.35 - Nursing services  Cornell Law Scholl Legal Information Institute.  42 CFR § 483.30(c)      https://www.law.cornell.edu/cfr/text/42/483.35   
   
(7)  2019 CDC Threat Report  https://www.cdc.gov/DrugResistance/Biggest-Threats.html
  
(8)  McKinnell JA, Singh RD, Miller LG, Kleinman K, et al.  The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California.  Clin Infect Dis. 2019 Oct 15;69(9):1566-1573. doi: 10.1093/cid/ciz119.    https://www.ncbi.nlm.nih.gov/pubmed/30753383
   
(9) Antibiotic Use.  Center for Disease Dynamics, Economics & Policy.  Antibiotic Resistance Map.  https://resistancemap.cddep.org/AntibioticUse.php   

(10)  Antibiotic Use Nursing Homes, 2017.  Centers for Disease Control and Prevention.    https://www.cdc.gov/antibiotic-use/stewardship-report/nursing-homes.html
  
(11)  42 CFR § 483.45 - Pharmacy services.  Cornell Law School Legal Information Institute.  42 CFR § 483.45(f)(1)     https://www.law.cornell.edu/cfr/text/42/483.45
   
(12)  42 CFR § 483.30 - Physician services  Cornell Law Scholl Legal Information Institute.  42 CFR § 483.30(c)      https://www.law.cornell.edu/cfr/text/42/483.30   

(13) Roghmann MC, Johnson JK, Sorkin JD, Langenberg P, Lydecker A, Sorace B, Levy L, Mody L. Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to Healthcare Worker Gowns and Gloves During Care of Nursing Home Residents. Infect Control Hosp Epidemiol. 2015 Sep;36(9):1050-7. doi: 10.1017/ice.2015.119. Epub 2015 May 26.   https://www.ncbi.nlm.nih.gov/pubmed/26008727

(14)  Blanco N, Johnson JK, Sorkin JD, Lydecker AD, Levy L, Mody L, Roghmann MC.  Transmission of resistant Gram-negative bacteria to healthcare personnel gowns and gloves during care of residents in community-based nursing facilities. Infect Control Hosp Epidemiol. 2018 Dec;39(12):1425-1430. doi: 10.1017/ice.2018.247. Epub 2018 Oct 8.   https://pubmed.ncbi.nlm.nih.gov/30293533/

(15)  Knelson LP, Williams DA, Gergen MF, Rutala WA, Weber DJ, Sexton DJ, Anderson DJ; Centers for Disease Control and Prevention Epicenters Program. A comparison of environmental contamination by patients infected or colonized with methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci: a multicenter study. Infect Control Hosp Epidemiol. 2014 Jul;35(7):872-5. doi: 10.1086/676861. Epub 2014 May 7.  https://pubmed.ncbi.nlm.nih.gov/24915217/

(16)  Chang S, Sethi AK, Stiefel U, Cadnum JL, Donskey CJ.  Occurrence of skin and environmental contamination with methicillin-resistant Staphylococcus aureus before results of polymerase chain reaction at hospital admission become available. Infect Control Hosp Epidemiol. 2010; 31(6):607-12. doi: 10.1086/652775.    https://pubmed.ncbi.nlm.nih.gov/20397963/
  
(17) Alam MT, Read TD, Petit RA 3rd, Boyle-Vavra S, Miller LG4, Eells SJ, Daum RS, David MZ. Transmission and microevolution of USA300 MRSA in U.S. households: evidence from whole-genome sequencing. MBio. 2015 Mar 10;6(2):e00054. doi: 10.1128/mBio.00054-15.  https://pubmed.ncbi.nlm.nih.gov/25759497/
 
(18)  Allegranzi B, Bischoff P, de Jonge S, Kubilay NZ, Zayed B, Gomes SM, Abbas M, Atema JJ, Gans S, van Rijen M, Boermeester MA, Egger M, Kluytmans J, Pittet D, Solomkin JS; WHO Guidelines Development Group.  New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective.  Lancet Infect Dis. 2016 Dec;16(12):e276-e287. doi: 10.1016/S1473-3099(16)30398-X. Epub 2016 Nov 2.   PMID:   27816413   https://pubmed.ncbi.nlm.nih.gov/27816413/
 
(19)  Zimmerman FS, Assous MV, Bdolah-Abram T, Lachish T, Yinnon AM, Wiener-Well Y. Duration of carriage of carbapenem-resistant Enterobacteriaceae following hospital discharge. Am J Infect Control. 2013;41(3):190–4.   https://linkinghub.elsevier.com/retrieve/pii/S0196655312012680

(20)  Albrich WC and Harbarth S.(2008). Healthcare workers: source, vector, or victim of MRSA? Lancet Infect. Dis. 8,289–301.doi:10.1016/S1473- 3099(08)70097-5 http://www.thelancet.com/journals/laninf/article/PIIS1473309908700975/abstract