Six keys to an effective infection preventionist

Despite best efforts in many skilled nursing facilities, infection prevention and control remains an issue. So much so that infection control citations remain among the top 10 survey deficiency tags nationally.

According to the Centers for Medicare & Medicaid Services (CMS), there are between 1.6 and 3.8 million healthcare-associated infections in long-term care facilities annually, which result in an estimated 150,000 hospitalizations and 388,000 deaths. Residents in long-term care “may be more susceptible than individuals in other types of healthcare facilities due to malnutrition, dehydration, comorbidities, or functional impairments, such as urinary and fecal incontinence, or medications that diminish immunity or mobility” (Federal Register, Vol. 81, No. 192, p. 68807). As a result, CMS has mandated the role of an infection preventionist; this will be implemented in Phase 3 of the final rule’s implementation on November 28, 2019.

The role of the preventionist

CMS indicated that the infection preventionist (IP) can be one or more individual(s) in the facility who are responsible for the facility’s IPCP (Federal Register, p. 68810). According to the final rule, “each facility should have the flexibility to determine how their facility should comply with the requirements in this final rule, including which individuals should be designated as the IP(s)” (Federal Register, p. 68810). An infection preventionist can be anyone in the facility who has primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field. The IP must be qualified by education, training, experience, or certification; must work at least part-time in the facility; and must have completed specialized training in infection prevention and control. This means that if you have an infection control nurse already, that staff person likely qualifies to take on the IP role (in part due to experience), although in some cases further training may be required. This also means that the IP could be another nurse, a DON, or anyone working in your facility who has training as described above.

Key responsibilities

The regulation is written to provide flexibility for facilities, but the infection preventionist should be charged with both process surveillance and outcome surveillance. The State Operations Manual Appendix PP (F441 Intent §483.65, “Infection Prevention and Control Program”) describes the two procedures. Process surveillance “reviews practices directly related to resident care in order to identify whether the practices comply with established prevention and control procedures and policies based on recognized guidelines. Examples of this type of surveillance include monitoring of compliance with transmission based precautions, proper hand hygiene, and the use and disposal of gloves.” 

Outcome surveillance, on the other hand, “is designed to identify and report evidence of an infection. The outcome surveillance process consists of collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections. The IP or other designated staff reviews data (including residents with fever or purulent drainage, and cultures or other diagnostic test results consistent with potential infections) to detect clusters and trends.”

Tasked with both levels of surveillance, your infection preventionist should do the following:

• Ensure that infection control policies and programs are up to date, understood, and followed correctly. No policies are effective if staff members do not know or understand them. The IP should be responsible for staff training that directly impacts infection prevention and control. 
• Ensure that policies for resident immunizations specifically for influenza and pneumococcal disease are updated according to current guidelines, understood, and followed correctly. When a resident is admitted, not all immunizations are necessarily included in the medical record. It is important to work closely with the resident and resident’s representative to ensure that the nursing staff is aware of all immunizations that have been previously administered and immunizations that the resident might need.
• Ensure a system is in place to document incidents. The IP should be responsible not only for the documentation system but also for identifying infection trends through root-cause analysis and sustainable corrective actions. 
• Start planning for the antibiotic stewardship program and start trending. The IP should have a good sense for the facility’s current antibiotic trends, which will greatly help to inform the antibiotic stewardship program as required in Phase 2 on November 28, 2017. The IP should be responsible for overseeing the antibiotic stewardship program and continuously improving the system in place to monitor antibiotic use. 
• Train on infection control. Training should take place both on an ongoing basis on the basics of infection prevention and control (the process for isolation procedures, hand hygiene, food handling, etc.) and when need arises in response to incidents. 
• Participate in QAPI. The IP should report on infection control and prevention measures, trends, and issues in the facility as part of the QAPI process with the leadership team.

Prevention, prevention, prevention

It is true that you can’t be all things to all people. When I was a DON on a small unit with fewer than 50 residents, I was the infection control nurse in addition to all my other responsibilities. When a resident with dementia started eating less one day, I looked at her chart for medication changes and I checked her mouth for sores, but I found nothing significant. In the first few hours before more severe symptoms set in, we didn’t recognize that the resident was falling ill with a gastrointentinal virus, and that she would be only the first of many. Within 24 hours, another resident followed. A norovirus spread like wildfire and within 48 hours, six residents and six staff members were violently ill. 

In our later investigation into the root cause of why the infection spread, we discovered two causes. First, the kitchen had allowed an employee who was sick to come to work. The thinking from the kitchen manager was that, because the kitchen employee didn’t interact directly with residents, there was no risk that the illness would spread. Of course, the infection did spread because the individual was handling resident food. The second cause was a lack of appropriate handwashing, and because of this the illness spread faster. In all, 24 out of 39 residents contracted the virus, which moved swiftly through the unit. Following the incident, the leadership in-serviced kitchen managers regarding when staff should and shouldn’t work.

If we had had an infection preventionist, with specialized training and a working knowledge of infection issues in the facility, perhaps this person could have identified a virus at the first signs. We didn’t. In its mandate, CMS acknowledged receiving comments that adding this new role would pull on strained resources in some facilities and in response stressed that this role is necessary for resident care and safety. If implemented correctly, it certainly will improve both.

Time for new responsibilities

So what does this mean for facilities? A new full-time employee? A new set of responsibilities for your DON? Enhanced training requirements for your current infection control nurse? This new role is important and will prevent infections and citations in the future, so it’s important that the person assuming the role has the capacity to successfully do so.

CMS estimates that the newly mandated infection prevention responsibilities should consume 15% of an RN FTE’s role, but this will vary based on facility size (Federal Register, p. 68842). Here are some tips for selecting the right staff member and making sure that your future infection preventionist isn’t spread too thin:

• Use the preparation window to train your IP nurse properly. Ensure that he or she not only is trained on infection control issues, but also understands the complete scope of the role—from identifying trends to training staff. 
• Choose someone who is well versed in root-cause analysis. Your infection control program will have the most success if you select a nurse who is adept at data collection as well as analysis. 
• Assess how you handle employee infections, starting now. Be sure to track infections for all employees, not just those within the nursing department. Knowing what trends exist in your facility now will help your infection preventionist successfully get up to speed later. 
• Don’t overburden the IP, especially as this person adjusts to his or her new role and responsibilities. This could cause burnout, or simply cause duties related to infection prevention to take a back seat. Also, keep in mind that the time needed for the duties assigned to the IP may change as resident acuity changes and/or when there is an increased chance of infections (October–March). 
• Drug expertise is key. Especially given that the antibiotic stewardship program is mandatory one year prior to the IP’s being so, it is key to ensure that the IP has not only drug expertise but also the knowledge to successfully manage the antibiotic stewardship program. 
• Make sure staff members understand the new IP role. If staff understand the new role, they will be more successful in relaying the proper information and providing the proper documentation.

While we don’t know everything that the IP will be required to take on, or exactly what it will look like in skilled nursing facilities of different sizes, we will eventually have more clarity through the new SOM and interpretive guidelines for surveyors. What we can be sure of now is that it’s never too early to start looking ahead, especially as the season for sniffles sets in.

Amy Stewart, RN, RAC-MT, DNS-CT is a subject-matter expert for The American Association of Directors of Nursing Services.

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