ICCS Infection Prevention & Infection Control Newsletter: 2020 Year in Review

Another year is behind us, and what a year it was. Let's look back at what happened with infection prevention and control during 2020 in this special edition of the ICCS Infection Prevention & Control Newsletter, beginning with a section dedicated to the biggest development of the year.

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WHO Statement Regarding Cluster of Pneumonia Cases in Wuhan, China — On January 9, WHO issued its first statement concerning what would become the COVID-19 pandemic.

First Travel-Related Case of 2019 Novel Coronavirus Detected in United States — On January 21, CDC confirmed that a Washington resident was the first person in the US with a confirmed case of the novel coronavirus.

Secretary Azar Declares Public Health Emergency for United States for 2019 Novel Coronavirus — At the end of January, HHS declared a public health emergency for the entire US. The announcement came around the same time that WHO declared a global health emergency, among many other developments.

CMS: Review Infection Prevention and Control Policies and Practices Now — In mid-February, CMS issued a memo reminding healthcare facilities about the importance of compliance with infection control practices as the spread of COVID-19 continued.

WHO Declares COVID-19 a Pandemic — On March 11, WHO declared COVID-19 a pandemic. Two days later, the novel coronavirus was declared a US national emergency. This was occurring as dangerous myths about prevention of and treatment for the COVID-19 were circulating and increasing in intensity.

California Becomes First to Issue Statewide Stay-at-Home Order — On March 19, California became the first state to issue a stay-at-home order and direct healthcare systems to prioritize services to the sickest patients.

United States COVID-19 Death Toll Surpasses 100,000 — On March 28, CDC announced that the number of people in the US who had died from COVID-19 surpassed 100,000.

States Rolling Out Mandates for Long-Term Care Facilities — In the summer, we began to see states rolling out COVID-19 mandates for long-term care facilities as CMS began resuming inspections, indicated plans for its own expansion of requirements, and increased noncompliance penalties.

FDA Issues EUA for First COVID-19 Vaccine — On December 11, FDA issued the first emergency use authorization to the Pfizer/BioNTech COVID-19 vaccine. A few days later, the FDA issued its second EUA to the Moderna COVID-19 vaccine.

First Coronavirus Vaccine Shots Given Outside Trials In U.S. — In between the issuing of the EUAs, Sandra Lindsay became the first American to receive the coronavirus vaccine outside a clinical trial.

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Note: The stories shared above represent a fraction of 2020's most significant developments concerning the COVID-19 pandemic. AJMC and NBC News are among the publications and organizations maintaining timelines about the pandemic that identify other substantial announcements and developments. While COVID-19 was undoubtedly the defining story of 2020, there were a number of unrelated, yet still significant infection prevention and control developments from 2020 to know.

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Future of Infection Prevention: Q&A With Consultant Phenelle Segal — ICCS Founder Phenelle Segal answered 10 questions concerning the future of infection prevention in the COVID-19 era.

FDA: Stop Using Certain Cardinal Health Surgical Gowns, Packs — Early in the year, the FDA advised providers to discontinue use of certain Cardinal Health surgical gowns and PreSource procedural packs that included the surgical gowns because of possible contamination. Cardinal initiated a recall around the same time. While the company sought to address its shortages, the recall was further magnified by the PPE shortages that surged during the pandemic.

WHO Urgent Challenges List Includes Infectious Diseases, Anti-Microbial Resistance — WHO issued its "urgent health challenges for the next decade" list. Included on the list: "stopping infectious diseases" and "protecting the medicines that protect us," which focuses on anti-microbial resistance.

KHN: Nursing Homes Struggling With 'Basic Infection Prevention Protocols' — A Kaiser Health News report highlighted the struggles of many nursing homes around the country with following "basic infection prevention protocols," with a federal records analysis revealing that about 61% of all such facilities were cited for one or more infection-control deficiencies since the beginning of 2017.

Infection Prevention Standards Challenge AAAHC-Accredited Facilities — Infection prevention and safe injection practice standards continued to be among those with high deficiency percentages for organizations accredited by the Accreditation Association for Ambulatory Health Care.

Joint Commission Infection Control Standards: Most Challenging for Accredited Ambulatory Healthcare Organizations — The Joint Commission identified its most challenging standards for accredited ambulatory healthcare organizations in 2019, with infection control standards as the most and second most challenging for the year.

ECRI: Sterile Processing, Antimicrobial Stewardship Top Patient Safety Concerns — Challenges concerning sterile processing and antimicrobial stewardship appeared on the ECRI Institute's "Top 10 Patient Safety Concerns for Healthcare Organizations 2020" report.

High Infection, Injury Rates Lead to Medicare Penalties for Several U.S. News' 'Best Hospitals' — As this report showed, every facility — no matter how many awards or recognitions its earned — has room for improvement concerning infection prevention and control.

Unsafe Injection Practices Endanger Thousands of Patients — A study revealed that nearly 67,000 patients were notified about potential exposure to unsafe injection practices by healthcare personnel between 2012 and 2018.

New S. aureus Guidelines for NICU — CDC issued new recommendations for the prevention and control of Staphylococcus aureus, including MRSA and MSSA, in infants in neonatal intensive care units.

Study: Doctors’ Phones Too Often Contaminated by MRSA — This study served as a helpful reminder about the importance of cleaning and disinfecting our mobile technology.

10 of the Scariest Healthcare Infections and Threats (2020 Edition) — ICCS produced its second annual list of scariest healthcare infections and threats to coincide with Halloween.

Special Report: What to Know About Standard Precautions — Early in the year, the ICCS team issued a special report that took a deep dive into the concept of "standard precautions."

Nursing Homes: CMS Adds New Triggering Factors for Focused Infection Control Surveys

The Centers for Medicare & Medicaid Services (CMS) has expanded the criteria that will trigger a focused infection control survey at a nursing home, according to a revised CMS memo.

The new criteria are as follows:

• multiple weeks with new COVID-19 cases;

• low staffing;

• selection as a "special focus facility" per the Social Security Act;

• concerns related to conducting outbreak testing per CMS requirements; or

• allegations or complaints which pose a risk for harm or immediate jeopardy to the health or safety of residents which are related to certain areas, such as abuse or quality of care (e.g., pressure ulcers, weight loss, depression, decline in functioning).

The revisions come now that there is the increased availability of resources for the testing of residents and staff and factors related to the quality of care, CMS notes.

CMS indicated that it is working with state survey agencies to identify facilities that meet the above criteria. The focused infection control survey, which will be performed by the state agencies, are to start within 3-5 days of identification. CMS noted that facilities which meet the criteria to trigger a survey will not need to be resurveyed if a focused survey was conducted within the previous three weeks.

The updated memo also notes that surveyors performing the focused infection control surveys should keep an eye out for and then investigate concerns related to residents who have experienced a significant decline in their condition during the public health emergency.

As McKnight's Long-Term Care News reports, the memo builds upon requirements issued in the middle of 2020. "Since June, CMS has required states to perform onsite infection control-focused surveys by the end July at nursing homes with previous COVID-19 outbreaks, or within three to five days of any nursing home with three or more new confirmed cases since their last report to the National Health Care Safety Network."

Infection Control Consulting Services (ICCS) is actively assisting many nursing homes working to comply with survey requirements and continuing to implement COVID-19 prevention practices. To learn more ICCS's COVID-19-related services, click here.

Future of Infection Prevention: Q&A With Consultant Phenelle Segal

Phenelle Segal, RN, CIC, FAPIC, founder of Infection Control Consulting Services (ICCS), answers 10 questions concerning the future of infection prevention in the COVID-19 era.

Q: What trends are you seeing across the non-acute sites that you work with when it comes to infection prevention during COVID-19?

Phenelle Segal: Across the board, non-acute-care sites, including outpatient settings, that were unfamiliar with pandemic preparedness, particularly droplet precautions and the level of personal protective equipment (PPE) required for a virus like COVID-19, have risen to the occasion and shown incredible diligence and expedience in turning their sites into "COVID-safer" sites. The trend for being "COVID-safe" is continuing, and I'm not seeing any pull back to "previous times," which is encouraging. COVID-19 is here to stay for an extended period, and the non-acute sites need to maintain this level of diligence moving forward.

It's worth noting that in August, the governor of New Jersey enacted an executive order encompassing all long-term care settings in response to the severity of outbreaks that occurred in the New York tri-state area (New York, New Jersey, and Connecticut) at the beginning of the pandemic. To fulfill the requirements outlined in this order has required extensive work and communication strategies. These requirements and mandates have resulted in solidifying policies and procedures. However, regardless of state mandates, the pandemic has led to a major emphasis placed on processes, particularly in long-term care, and greater oversight is now in effect.

Overall, I'm seeing a healthcare community outside of acute care that has always had a strong commitment to infection prevention and adhering to a robust program truly rising to the forefront of the COVID-19 health crisis.

Q: How has infection prevention since COVID-19 changed? What do you see happening in the future?

PS: Adherence to the status quo and repeating the same processes over and over, depending on the facility, has definitely changed and is evolving. Existing protocols have tightened up and new protocols have been introduced. Staffing has been challenging and needed to be adjusted for a few reasons. When we were shut down, many non-acute sites had to furlough staff, with some choosing to leave the healthcare arena to find alternate work. As a result, many didn't return to their previous jobs when we started opening up. That resulted in a shortage of skilled workers.

In addition, many staff members have school-age children. For staff with such children doing remote learning, they needed to change their work strategies to accommodate staying home with their children.

Last but not least, COVID-19 fatigue has resulted in many healthcare workers leaving their jobs and finding other, less stressful professional avenues. Going forward, education will remain a huge necessity, especially teaching practices unfamiliar to healthcare workers, such as donning and doffing of PPE that was primarily performed in the acute-care setting. Non-acute-care settings have needed to figure out how to train and educate staff and then establish compliance monitoring and strategies for reporting with feedback as well.

Q: What should facilities be doing now to prepare for what's next?

PS: Continue to enforce and maintain protocols and practices that were developed and be mindful of letting one's guard down, particularly in the areas of the country that have experienced a low or steady downward trend of coronavirus cases. I'd also encourage facilities to consider increasing PPE and disinfectant supply resources as the winter months are upon us and we are seeing an exponential increase in cases before the true winter months get here. This is of great concern. Maintaining diligence, communication, and auditing of processes remains paramount in fighting this pandemic.

Q: Following up on the previous questions, what do you see as the biggest challenges to preparing properly?

PS: Several challenges continue across the continuum of care: Restricted supplies, particularly N95 masks, counterfeit KN95s, shortage of disinfectant wipes; budget constraints as a result of several unforeseen costs; overall staffing issues and COVID-19 healthcare worker burnout (as discussed earlier), particularly caused by high levels of professional and personal stress, along with the wearing of PPE, depending on the facility setting and services provided. Maintaining effective communication can be a challenge but is absolutely essential. Managers need to maintain an open-door approach and share information from external sources, such as state orders and CDC guideline changes, and internal information.

Q: How should facilities approach new regulations resulting from COVID-19, and what do you see as the potential long-term impacts?

PS: The biggest challenge with new regulations, particularly at the individual state level, is the difficulty in interpreting the language as written in the new orders and requirements. Many would argue that regulations are mostly subjective and open to interpretation. This has resulted in much confusion and anxiety thus far, especially for administrators and management teams as they are struggling to comply with the law and put new practices into place. That being said, I expect it to get easier as time moves on and we become more used to the "new normal."

Q: How does all of this compare to past pandemics?

PS: There is no comparison that I can accurately discuss, but what I can do is mention that this is most likely the pandemic of all pandemics, akin to an earthquake when we talk about the big one. Lessons learned from this will certainly carry over to future pandemics, but ones that we can only hope are not as devastating as this one. I don't believe this will be our last major respiratory pandemic, but we certainly will be better prepared for the next crisis.

Q: Ambulatory surgery centers (ASCs) are now required to have an infection preventionist on staff. What should administrators, owners, and human resources leaders consider when they start their search for this new staff member or are they better off certifying someone from within?

PS: Hiring from the outside or training someone from within is very much dependent on several factors, including the type of facility and services offered by the surgery center as well as the infection prevention designee's skills, interest in taking on this role, time allocation, and other factors. It also depends on the current state of the infection prevention program. What is the "right approach" for ASCs will be very much individualized. Many surgery centers appoint an infection prevention designee and hire an external consultant to onboard and assist the designee with developing and implementing a new program or maintaining an already established program.

Q: Can you please clarify the guidance around an infection preventionist on staff for a long-term care/skilled nursing facility?

PS: Between the end of 2016 and 2019, long-term care facilities were mandated to include several infection prevention components for participation. This culminated in designating staff members to the role of infection prevention that included specialized training. With COVID-19 attacking the elderly in facilities since March, individual states have recently enacted executive orders, for example the aforementioned New Jersey order and an order from California in late September. These requirements, depending on the state, can be very stringent.

Q: As home health providers need to treat patients in home, what are recommended practices for home health staff to protect themselves while keeping patients safe?

PS: Follow CDC guidance and the basic principles of prevention of acquisition and/or transmission of COVID-19. In addition, the National Association for Home Care and Hospice has an extensive resources page that I would encourage everyone that is involved in home health to review. The page includes FAQs, information for patients and caregivers, and much more.

Q: Can you share any insights on updated point-of-care (POC) testing protocols for providers?

PS: POC technology is changing frequently. Companies are turning out products that are easier to administer, turnaround faster, and produce fewer false negative results. However, testing is not foolproof. Besides facilities enacting their own rules and policies around testing, what facilities need to do will also be dependent on state regulations. POC testing is mandated in several states for long-term care settings due to the outbreak risks in those settings. I believe that will continue into next year as we expect cases to rise again with winter around the corner. It is important to understand that POC testing has limitations; consider exactly what your goals are for doing POC testing and how you will use these results.