The tool uses existing evidence to form recommendations for staffing ratios in long-term care, acute and ambulatory care settings. All of the recommendations are based on key risk factors.

“We are excited to provide this tool to the infection prevention field,” Patricia Jackson, RN, president of APIC, said in a statement. “APIC members have been asking for a resource to help quantify staffing needs for years, and now we can begin to deliver on that promise. With member input, we will be able to provide a robust, accurate staffing tool that will help IP leaders make the case for adequate staff and resources to protect patients.”

The introductory version of the staffing calculator is an “exploratory approach,” APIC says. That is, it’s intended to provide a basic calculation of staffing needs and will collect data that can be used for creating a more rigorous algorithm in the future. 

Data gathered from healthcare facilities that use the tool will be utilized to update it so the tool improves over time. In the next year, an updated version will be released to reflect the accumulated data. In addition to updating the tool as it rolls out, APIC said that it will produce annual reports summarizing data to drive deeper insights into its effectiveness.

The news comes as more organizations are hiring chief infection prevention officers (CIPOs). An article published Dec. 7 in Infection Control Today shared details on this executive role that supports operational positions through the lens of preventing infection.

Now we are sounding the alarm again over a particularly problematic missed opportunity: the Biden Administration’s recently announced efforts to address overall nursing home staffing requirements. The requirements are a step in the right direction for direct patient care. But the effort fails to protect nursing home residents from infections.

That’s important because the Government Accountability Office found that from 2013 to 2017, 82% of all inspected nursing homes had an infection prevention and control deficiency identified through Medicare and Medicaid surveys. 

During the pandemic, 34% of deaths were linked to nursing homes. Those with more than 40% minority residents reported coronavirus case and death counts that were 3.3 times higher than facilities with more than 97% white residents. 

The consequences remain deadly, even after the COVID-19 pandemic has ended. There are between 1.6 and 3.8 million HAIs in long term care every year. Around 380,000 of those patients died each year, prior to the pandemic. 

The lack of data collection is also problematic. Nursing homes are not required to track infections through the CDC’s National Healthcare Safety Network,, unlike hospitals which have had HAI reporting requirements since 2011. When hospitals started tracking infections and made that data public, improvements followed, and HAI rates declined.

Not surprisingly, when surveyors inspect nursing homes, infection control is the most common type of deficiency cited. Still the Centers for Medicare & Medicaid Services leaves it up to nursing home owners and operators to determine if resources should be dedicated to protecting patients. 

Specifically, CMS does not require that each nursing home employ a full-time, onsite, infection control professional who is fully dedicated (meaning that infection prevention is their sole function) to ensuring that the facility has an infection prevention and control plan and that it is being followed. 

In September 2020, a CMS-commissioned MITRE Corporation report stated that, “this position [infection preventionist] is traditionally assigned to a supervisor, nursing manager or provider as an added (rather than a core) responsibility, yielding insufficient response to the demands of the current pandemic.” 

Instead of a full-time person dedicated to the role, infection prevention responsibilities have become an afterthought, designated to a part-timer as an added duty. Part-time IPs spend less than a third of their time on critical infection prevention and control (IPC) work like establishing IPC protocols, conducting surveillance and scouring electronic health records and lab reports for clues about deadly pathogens.

Without a dedicated and trained infection preventionist, no one is in place to create protocols, properly train staff on how to prevent transmission of infectious diseases, or ensure that a facility’s policies are being followed. 

Unless the government acts and requires a full-time dedicated infection preventionist and reporting of HAIs, nursing home residents will continue to suffer disproportionately from infectious threats. Why do we allow nursing homes to have lower standards than hospitals when it comes to protecting our most vulnerable fellow citizens? 

Devin Jopp, EdD, MS is the CEO of the Association for Professionals in Infection Control and Epidemiology (APIC), the 15,000-member association for infection preventionists and epidemiologists.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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“Despite years of government reports sounding the alarm about infection control lapses in nursing homes … there remains an astonishing lack of attention to infection prevention and control in nursing homes,” the Association for Professionals in Infection Control and Epidemiology wrote in a letter to the top four leaders in Congress. “For too long, IPC has been under-resourced and put on the back burner. Although nursing staff is essential to patient care, they must rely on specialized training and expertise of IPs to oversee facility-wide infection prevention. Lessons learned from COVID-19 have proven that IPC needs to be a priority for facilities.”

The letter comes as the long-term care sector waits for the Centers for Medicare & Medicaid Services to release its highly anticipated staffing minimum rule. Sector observers expect it to call for approximately 4.1 hours of direct care per patient day. 

APIC wants to see the federal government require facilities to have a full-time infection control specialist on staff to develop procedures to prevent transmission of infectious agents and enforce control standards. The Center for Disease Control estimates there are one million to three million infections per year at long-term care facilities, the letter says.

The association also calls for educating surveyors in infection control and prevention to ensure they are holding facilities accountable. In addition, it calls for individuals responsible for training others to be certified in infection prevention and control, education that is provided by the association. 

“Federal efforts to train staff in nursing homes have, at times, been limited due to failure to understand that the practice of infection prevention and control requires specialized knowledge,” the letter said. It added that the “minimum competency requirements for trainers should be a Long-Term Care Certification in Infection Prevention or Certification in Infection Prevention and Control. 

In June 2022, the Centers for Medicare & Medicaid Services announced that staffers responsible for infection control in nursing homes did not have to be employed there full-time, but were required to have someone there with appropriate infection control training “on site,” instead of an off-site consultant or a person working in a corporate office. McKnight’s Long-Term Care News reported that a compromise reached by the agency with a sector experiencing a workforce crisis was that facilities would need an IP with “specialized training onsite at least part-time to effectively oversee the facility’s infection prevention and control program.”

Infection prevention is frequently seen as “other duties as assigned to people who are not very good at saying ‘no,’” said Deb Burdsall, PhD, CIC, a consultant with the Association for Professionals in Infection Control and Epidemiology and the Illinois Department of Health, to McKnight’s on Friday.

“We need more people in long-term care interested and trained as infection preventionists who are given the time to do the job,” she said, adding that effective prevention and controls are the “best way to avoid and minimize the personal and economic burden of infections.”

“While we have come a long way from the beginning of the COVID-19 pandemic, the virus remains a threat, especially to older adults and those with underlying health conditions,” wrote AHCA President and CEO Mark Parkinson. “COVID-19 variants continue to emerge, and your administration and other public health experts have issued repeated warnings about a potential surge of cases this fall and winter. As you know, high spread of COVID in surrounding communities has been linked to nursing home outbreaks.”

“Extending the PHE is critical to ensure states and healthcare providers, including long-term care providers, have the flexibilities and resources necessary to respond to this ever-evolving pandemic,” he added.

Becerra confirmed last month that his department still plans to give providers 60 days’ notice of the PHE’s end, meaning that it should become clear late next week if an additional extension is in the works. Many healthcare providers and health systems are anxiously awaiting a decision.

The easing of COVID-19 restrictions like masking and social distancing is mainstream in the general public and the CDC has left the decision to mask up to facilities based on their community risk levels. Those factors have raised alarm bells from non-AHCA nursing home advocates, as those protocols were in part responsible for not only keeping COVID-19 spread down, but also decreasing flu outbreaks compared to pre pandemic years.

“With surging RSV cases and the early arrival of flu, combined with limited use of masking, social distancing, and other protective measures – we are already seeing ER departments filled,” Devin Jopp, EdD, CEO of the Association of Professionals in Infection Control and Epidemiology, told McKnight’s Long-Term Care News.

“While we cannot say with certainty, based on historical trends, it is reasonable to assume that COVID-19 cases will rebound this winter along with the fall/winter holiday season.”

Parkinson also pleaded with Becerra to support PHE extension because he is concerned that much of the country is unprepared for the administrative backlog the end of the PHE will bring. He cited a Georgetown University report that said 22 states have no plan for expected Medicaid coverage disruptions, and another 10 have minimal plans. Officials at the Centers for Medicare & Medicaid Services said Tuesday that they were working on guidance that would help providers manage the end of waivers and relaxed rules that are connected to the PHE.

But an additional extension would give states and providers more time to ready themselves, Parkinson wrote.

“Redetermination specifically for the aged, blind, and disabled populations takes longer than other beneficiaries due to the need for a clinician to verify that the individual needs nursing home-level care as well as a review of all assets in addition to income,” he wrote. “All long-term care providers are struggling with soaring labor costs and inflation; they cannot absorb additional losses due to state errors.”

As with most viruses, the youngest and oldest are hit hardest by infection, so nursing home staff and residents should be on highest alert to continue what COVID-19 fears jump-started: extreme source control and hand hygiene, said APIC consultant Deborah Burdsall, PhD RN-BC, CIC, Wednesday.

This is not a time for mask fatigue to win, she emphasized to McKnight’s Long-Term Care News. 

“When people focus on one organism, like SARS-Cov-2, they forget that core principles of infection prevention are important to prevent other infectious organisms as well,” said Burdsall, who added that the bugs RSV and Adenovirus can also be hazardous for seniors.  

“While we were in the height of the COVID pandemic and people were staying home and masking, the number of cases of other respiratory illnesses dropped precipitously. We didn’t have a normal flu season, we didn’t have a normal RSV season, we didn’t have a lot of the respiratory virus that we see that causes major outbreaks in congregate settings,” Burdsall explained.

During Tuesday’s panel discussion on flu season hosted by the National Foundation for Infectious Diseases, experts cautioned that flu infection indicators elsewhere this year are ominous and that everyone older than six months should get one of the three new flu vaccines available.

“Based on what we have seen in parts of the Southern Hemisphere, flu has the potential to hit us hard this year,” said NFID Medical Director William Schaffner, MD. “On a positive note, we have more preventive behaviors in our toolbox than we did before the COVID-19 pandemic. We are more accustomed to wearing masks and staying home when sick.”

Burdsall said the danger this year is people dropping their COVID guard. The CDC recently loosened its masking guidelines for nursing homes, telling them it’s their call based on their surrounding area’s transmission data. 

“Because people have mask fatigue and PPE fatigue, people aren’t as careful as they were in, say, 2020 and in the 2020-2021 flu season,” Burdsall said. “If masks are not used, we’re back to a situation where it’s easy to transmit respiratory infection, especially in congregate settings.

“Make sure policies and procedures align with best evidence,” she advised providers. “People aren’t going to be stuck in masks forever but when there’s a lot of viruses floating around out there, people should do what they need to do to protect themselves and their residents.”

The Association for Professionals in Infection Control and Epidemiology on Monday cited indicators such as wastewater surveillance and increased COVID-19 case counts abroad as evidence of a potential wave of new COVID-19 cases in the coming months.

“Our members clearly understand that the pandemic is not over,” APIC said in a statement. “With more than 300 Americans still dying each week from COVID-19 and a virulent flu season predicted, now is not the time to risk patient or healthcare worker safety.”

CDC told healthcare facilities it can use its Community Transmission scale to decide if their workers child mask; locations within low-level transmission regions can ease masking standards. 

In addition to the oncoming flu season and evidence of COVID-19’s continued presence, APIC said the seven-day lag in CDC COVID-19 testing data could limit the ability to detect surges in real time.

“While APIC understands that many healthcare employees have grown weary of masking, we do not believe it is wise to discontinue this evidence-based, COVID-19 mitigation strategy,” the statement said. “As healthcare professionals, we are obligated to protect the vulnerable patients entrusted to our care. It is for this reason that we take annual flu shots, and stay up to date with other immunizations, including COVID-19. Requiring masks of anyone who enters a healthcare setting, including employees, helps to ensure the safest environment for our patients.”

The 15,000-member body said it is also worried a new COVID-19 surge could bring a return of masking mandates.

“Having a policy that changes back and forth is confusing to healthcare personnel and erodes trust,” it said. “Furthermore, rising COVID cases could lead to healthcare worker shortages, a situation we all want to avoid.”

APIC consultant Deborah Patterson Burdsall said masks had a use before the pandemic.

“Remember that a larger part of CDC’s respiratory etiquette was wearing masks for source control in healthcare during cold and flu season,” she said. “There is ample evidence that wearing source control reduces transmission of not only COVID-19 but other respiratory pathogens. 

“What some people don’t understand is that many long term care facilities have been stuck in N95s and goggles or face shields for what must seem like an eternity. The new CDC guidance does give the opportunity to focus on some of the evidence for PPE use. Just being able to work with a well fitting face mask may be a relief for some, but I would suggest it is premature to get rid of source control not only for healthcare personnel but also visitors and even residents in large group activities.”

The CDC on Sept. 23 loosened masking requirements and other pandemic guidance for healthcare facilities. Aside from instances where known respiratory illness is present, most facility staff need not wear a respirator, face mask or eye protection when providing patient care, as long as the surrounding county doesn’t have high COVID-19 community transmission levels, the CDC has advised.

Stick with source control

This must bring relief to long-term care providers after years of wearing N95s and goggles or face shields, said infection preventionist Deb Patterson Burdsall, PhD, RN-BC, of the Association for Professionals in Infection Control and Epidemiology (APIC). Even so, the risks of contracting COVID-19, flu and other respiratory illnesses remain high for workers and residents, she said.

“Just being able to work with a well fitting face mask may be a relief for some, but I would suggest it is premature to get rid of source control not only for healthcare personnel but also visitors and even residents in large group activities” as noted by the CDC, she said.

In fact, her organization on Monday asked its more 15,000 members, including long-term care specialists, to continue universal masking policies in all patient care areas.

“With more than 300 Americans still dying each week from COVID-19 and a virulent flu season predicted, now is not the time to risk patient or healthcare worker safety,” APIC said in a statement.

Surges, testing lag  

Other long-term care advocates have supported an easing of pandemic policy in an effort to help residents and staff gain a much-needed return to normal. LeadingAge, for example, has praised the CDC’s expansion of flexibilities for these healthcare providers and “the autonomous individuals they serve.”

But APIC foresees a potential loss public trust if health officials must sway back and forth on their recommendations if new waves of COVID-19 hit.

The organization pointed to predictions of a severe flu season, “with COVID-19 surges looming on the horizon.” It also noted that CDC has a seven-day lag on COVID-19 testing data which it said may limit the ability to detect surges in real time.

“As healthcare professionals, we are obligated to protect the vulnerable patients entrusted to our care,” APIC said in its statement. “Requiring masks of anyone who enters a healthcare setting, including employees, helps to ensure the safest environment for our patients.”

After more than two years of an infectious disease emergency, there may be nostalgia for the pre-pandemic core measures of infection prevention, Burdsall added. But even then, the CDC’s respiratory etiquette in healthcare was wearing masks and/or source control during cold and flu season, she reminded long-term care providers. 

“There is ample evidence that wearing source control reduces transmission of not only COVID-19 but other respiratory pathogens,” she said.

Deb Burdsall is an author of: Between a Rock and a Hard Place: Recommendations for Balancing Patient Safety and Pandemic Response, published in March 2022.

Between June and September, New York State officials investigated eight cases of Legionnaires’ disease at the Amsterdam Nursing Home, in Morningside Heights. Four of the eight people investigated died, including two who state health officials confirmed had the disease, according to a New York Times story. 

A third person, who didn’t die, also tested positive for the pulmonary disease typically carried by water. The other five cases involved people who had preliminary evidence of the disease.

It was not clear if Legionnaires’ was the primary cause of the deaths, a spokesman for the department told the New York Times. A staff member that answered the phone at Amsterdam had no comment.

A study published online earlier this year in Emerging Infectious Diseases found that the incidence of Legionnaires’ disease has been on the rise for more than 15 years. People can get the lung infection by breathing in small droplets of water containing Legionella bacteria. 

This past summer, Illinois signed into law legislation aimed at protecting senior living residents in the state from waterborne illnesses.

Prevention of outbreaks in SNFs are mostly the job of facility managers, Linda Dickey, RN, MPH, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology, told McKnight’s Long-Term Care News.

“The big thing is maintaining water systems properly, whether it’s a cooling tower or maintaining faucet heads or shower heads, even ice machines,” said Dickey, who has helped the American Society of Heating, Refrigerating, and Air Conditioning Engineers set Legionellosis risk management standards for building water systems in 2018.

“Appropriate maintenance is really critical.”

Dickey said the main role of clinical staff is to act once symptoms are seen.

“Unfortunately by then something might be brewing,” she said.

Healthy people can get the disease said Dickey, but places like hospitals and long-term care environments must be vigilant because of their population of vulnerable people. Once the disease has been detected in a water system, the next steps depend on the source, she said.

“Point-of-use filters, hot flush systems, you can put in water treatment systems,” she said. “It varies depending on the severity of the problem and if you can identify where it’s coming from.”

The Japanese study explored the clinical and financial impact of rapidly spreading respiratory infections in close quarters. Published today in the American Journal of Infection Control, it found one sick staff member added $12,000 in costs.

“This study perfectly quantifies what I’ve seen over the years and is a textbook case on the economic consequences of presenteeism,” Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, a leading infection preventionist, told McKnight’s Long-Term Care News Tuesday. “In a nutshell, this shows how even the best intentions are not enough if the proper precautions aren’t implemented in time.”

Burdsall spends much of her time visiting long-term care communities in Illinois. She noted how much potential there is to make similar mistakes in the US.

“Visitors or staff are the ones who unwittingly bring pathogens into their communities, and for various reasons, will work sick out of fears of losing their jobs or personal time off credits,” she said.

“Responsible people tend to be the ones who will come in sick because they don’t understand the consequences,” she added. “The study did a great job of showing cause and effect. If you use a lift and someone falls, there’s an immediate consequence to your actions. That’s not necessarily the case if you come in with a respiratory infection.”

To encourage or incentivize workers to stay home, Burdsall advised facilities to enact non-punitive policies. Better policies aimed at supporting staffing levels and curbing presenteeism can also be a recruiting tool, she said.

Tracing respiratory troubles

Study author Naoki Takayama, RN, of the National Hospital Organization Tenryuu Hospital in Japan, said the research is among the first to use statistical analysis to confirm the source and cost of a respiratory infection in a long-term care ward for patients with severe motor and intellectual disabilities. 

“It sheds light on the significant clinical and financial implications of healthcare workers coming to work while ill, a phenomenon known as presenteeism that is detrimental and challenging for many healthcare facilities,” Takayama said.

Respiratory tract infections account for more than 40% of deaths among vulnerable patients with severe motor and intellectual disabilities. While many such facilities, including the one involved in the current study, follow standard employee health-surveillance protocols to prevent such infections, consistent adherence to these protocols can be difficult.

The culprit, in this case, was a part-time employee with 10 years of experience who came to work despite having a cough, nasal discharge, sore throat, and headache. She completed a health screening checklist upon arrival for her shift and practiced standard precautionary measures such as wearing a surgical mask.

It was later discovered that the employee did not directly consult her supervisor, and her supervisor did not review the reported checklist, study authors noted.

The healthcare worker and all 17 patients recovered from their infections. The median time to recovery was 10 days.

Study authors noted how multiple issues may contribute to employees’ presenteeism, including concerns about lost income, lack of days off, burdening colleagues, and maintaining professionalism.

“The findings from this study suggest that identifying and eliminating the factors that contribute to employee presenteeism should be a priority for healthcare facilities and providers to better protect their patients and employees from infectious illness,” said Linda Dickey, RN, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology.

Investigators analyzed data collected at eight U.S. sites from 2012 to 2015. Fully 10% of infections caused by carbapenem-resistant Enterobacterales (CRE) were community- rather than healthcare-associated. Most of the community-associated CRE cases were caused by the superbug Escherichia coli (E. coli) in urinary tract infections. And these infections, in turn, were more likely to occur in people with fewer underlying conditions than in LTCF residents or hospital patients, the researchers reported. 

The study results are troubling, experts say. CRE is predominantly associated with infections in high-acuity ventilator-capable LTCFs and other healthcare facilities. There, it is tracked and managed with infection control and prevention protocols. But out in the community, it will be much more difficult to control, according to the Center for Infectious Disease Research and Policy at the University of Minneapolis (CIDRAP).

Although the relative percentage of these community-occurring infections is small, the fact that these organisms are spreading among people without typical risk factors was surprising, CDC epidemiologist and lead study author Sandra Bulens, MPH, told CIDRAP News.

“These are typically organisms identified in individuals with extensive healthcare exposure,” she said. “Seeing this spread into the community is a concern because of the potential to cause infections that are challenging to treat in a broader population.”

APIC weighs in

Infection control experts have taken note of the study results.

“This study provides important initial data regarding the potential for CRE to become more common in the community,” said Linda Dickey, RN, MPH, 2022 president of the Association for Professionals in Infection Control and Epidemiology, in a statement. “It also reinforces the need for continued CRE monitoring outside of healthcare settings to inform community infection prevention efforts and reduce the spread of serious, drug-resistant infections.”

Full findings were published in the American Journal of Infection Control.

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