Catherine Crawford Cohen

Infection prevention and control in nursing homes: a qualitative study of decision-making regarding isolation-based practices

Background Isolation-based practices in nursing homes (NHs) differ from those in acute care. NHs must promote quality of life while preventing infection transmission. Practices used in NHs to reconcile these goals of care have not been characterised. Purpose To explore decision-making in isolation-based infection prevention and control practices in NHs. Methods A qualitative study was conducted with staff (eg, staff nurses, infection prevention directors and directors of nursing) employed in purposefully sampled US NHs. Semistructured, role-specific interview guides were developed and interviews were digitally recorded, transcribed verbatim and analysed using directed content analysis. The research team discussed emerging themes in weekly meetings to confirm consensus. Results We inferred from 73 interviews in 10 NHs that there was variation between NHs in practices regarding who was isolated, when isolation-based practices took place, how they were implemented, and how they were tailored for each resident. Interviewees’ decision-making depended on staff perceptions of acceptable transmission risk and resident quality of life. NH resources also influenced decision-making, including availability of private rooms, extent to which staff can devote time to isolation-based practices and communication tools. A lack of understanding of key infection prevention and control concepts was also revealed. Conclusions and implications Current clinical guidelines are not specific enough to ensure consistent practice that meets care goals and resource constraints in NHs. However, new epidemiological research regarding effectiveness of varying isolation practices in this setting is needed to inform clinical practice. Further, additional infection prevention and control education for NH staff may be required.

Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study

Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. We conducted a multi-site qualitative study of NH personnel important to infection control. Audio-recorded interviews were transcribed verbatim and transcripts were analyzed using conventional content analysis. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for per-diem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs. Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals.

Transmission of health care-associated infections from roommates and prior room occupants: a systematic review

Pathogens that cause health care-associated infections (HAIs) are known to survive on surfaces and equipment in health care environments despite routine cleaning. As a result, the infection status of prior room occupants and roommates may play a role in HAI transmission. We performed a systematic review of the literature evaluating the association between patients’ exposure to infected/colonized hospital roommates or prior room occupants and their risk of infection/colonization with the same organism. A PubMed search for English articles published in 1990–2014 yielded 330 studies, which were screened by three reviewers. Eighteen articles met our inclusion criteria. Multiple studies reported positive associations between infection and exposure to roommates with influenza and group A streptococcus, but no associations were found for Clostridium difficile, methicillin-resistant Staphylococcus aureus, Cryptosporidium parvum, or Pseudomonas cepacia; findings were mixed for vancomycin-resistant enterococci (VRE). Positive associations were found between infection/colonization and exposure to rooms previously occupied by patients with Pseudomonas aeruginosa and Acinetobacter baumannii, but no associations were found for resistant Gram-negative organisms; findings were mixed for C. difficile, methicillin-resistant S. aureus, and VRE. Although the majority of studies suggest a link between exposure to infected/colonized roommates and prior room occupants, methodological improvements such as increasing the statistical power and conducting universal screening for colonization would provide more definitive evidence needed to establish causality.

Nursing Homes in States with Infection Control Training or Infection Reporting Have Reduced Infection Control Deficiency Citations

It is estimated that 1.6–3.8 million infections occur among US nursing home (NH) residents each year, although healthcareassociated infections (HAIs) may be largely preventable. To reduce HAIs, the Centers for Medicare and Medicaid Services (CMS) monitors NH infection control (IC) practices as part of the annual inspection survey that determines certification eligibility. Noncompliant NHs are issued a citation (ie, F-tag or “deficiency”). State Departments of Health (DOHs) have also responded to these problems through a variety of activities, information, and policies, including IC training resources for NH providers, advisories, formal working groups, or collaboratives to advise NH providers regarding IC and mandatory or voluntary HAI reporting by NHs to the DOH. To our knowledge, the effects of these activities have not been evaluated. Hence, our objective was to determine associations between specific state DOH activities and NH IC citation rates. Information regarding state activities to reduce infections in NHs was systematically collected from 50 states and the District of Columbia’s DOH Web sites between November 2012 and January 2013. Details regarding data collection were previously described. Data from the Certification and Survey Provider Enhanced Reporting (CASPER) system from 2013 (93.9%) or 2014 (6.1%) were used, as were data from the Area Health Resource File (AHRF). CASPER contains information collected during CMS annual NH inspections, including citations and facility characteristics. AHRF contains countylevel socioeconomic, demographic, and health descriptions. Multivariate logistic regression with regional and urbanicity fixed-effects and state clustering was used to test associations between IC-related citations and the presence of the following state DOH activities: (1) voluntary or mandatory reporting of NH infections; (2) an advisory board, working group, or collaborative focused on reducing infections in NHs; and (3) IC training available through the DOH Web site (excluding inspection-related information). The models included covariates to control for facility, resident population, and market characteristics similarly to those of other studies. Relationships between overall care quality citations and DOH activities were also evaluated to assess specificity. A significance level of 5% was set a priori. All analyses were conducted using Stata 13 statistical software. Data were available from 14,276 NHs; 91.3% of facilities were in states that provided IC training, 70.4% were in states with an advisory group or collaborative, and 9.7% were in states with mandatory or voluntary HAI reporting. In this sample, 37.6% and 64.3% of facilities received an IC-related or a care quality citation, respectively. In the multivariate analyses, NHs in states that had mandatory or voluntary HAI reporting were less likely to receive IC-related citations (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.49–0.75) or overall care quality citations (OR: 0.75; 95% CI: 0.55–0.95). NHs in states that provided IC training were less likely to receive IC-related citations (OR: 0.67; 95% CI: 0.48–0.86), and training was not related to overall care quality citations. The presence of a state advisory or collaborative was not associated with either IC-related or care quality deficiency citations (Table 1). The association between provider access to IC training and fewer IC-related citations was specific and strong. Using qualitative methods, we previously found the need for increased training opportunities for NH staff members, particularly for those in charge of IC programs. It is logical that state DOHprovided IC training would improve IC and result in an inverse relationship with IC-related citations. Inverse correlations between the presence of HAI reporting and both general care quality citations and IC-related citations may indicate that HAI reporting impacts quality generally. At the time of data collection, only 5 states had HAI reporting; 3 of these implemented reporting within the previous year. Other factors coinciding with NH HAI reporting in those states and that were not accounted for in our study may have affected care quality citations. Furthermore, the relationship

Comparative and cost-effectiveness research: Competencies, opportunities, and training for nurse scientists

BACKGROUND Comparative and cost-effectiveness research develops knowledge on the everyday effectiveness and value of treatments and care delivery models. PURPOSE To describe comparative and cost-effectiveness research; identify needed competencies for this research; identify federal funding; and describe current training opportunities. METHODS Published recommended competencies were reviewed. Current federal funding and training opportunities were identified. A federally funded training program and other training opportunities are described. DISCUSSION Fourteen core competencies were identified that have both analytic and theoretical foci from nursing and other fields. There are multiple sources of federal funding for research and training. Interdisciplinary training is needed. CONCLUSION Comparative and cost-effectiveness research has the opportunity to transform health care delivery and improve the outcomes of patients. Nurses, as clinicians and scientists, are in a unique position to contribute to this important research. We encourage nurses to seek the needed interdisciplinary research training to participate in this important endeavor. We also encourage educators to use the competencies and processes identified in current training programs to help shape their doctoral programs.

Isolation Precautions Use for Multidrug-Resistant Organism Infection in Nursing Homes

To examine factors associated with isolation precaution use in nursing home (NH) residents with multidrug‐resistant organism (MDRO) infection.

State focus on health care-associated infection prevention in nursing homes.

BACKGROUND Despite increased focus on health care-associated infections (HAI), between 1.6 and 3.8 million HAI occur annually among the vulnerable population residing in US nursing homes (NH). This study characterized state department of health (DOH) activities and policies intended to improve quality and reduce HAI in NH. METHODS We created a 17-item standardized data collection tool informed by 20 state DOH Web sites, reviewed by experts in the field and piloted by 2 independent reviewers (Cohens κ .45-.73). The tool and corresponding protocol were used to systematically evaluate state DOH Web sites and related links. RESULTS Three categories of data were abstracted: (1) consumer-directed information intended to increase accountability of and competition between NH, including mandatory HAI reporting and NH inspection reports; (2) surveyor training for federally-mandated NH inspections; and (3) guidance for NH providers to prevent HAI and monitor incidence. Only 5 states included HAI reporting in NH with differing HAI types and reporting requirements. CONCLUSION State DOH information and activities focused on NH quality and reducing HAI were inconsistent. Systematically characterizing state DOH efforts to reduce HAI in NH is important to interpret the effects of these activities.

Evaluation of conceptual frameworks applicable to the study of isolation precautions effectiveness

AIMS A discussion of conceptual frameworks applicable to the study of isolation precautions effectiveness according to Fawcett and DeSanto-Madeyas (2013) evaluation technique and their relative merits and drawbacks for this purpose. BACKGROUND Isolation precautions are recommended to control infectious diseases with high morbidity and mortality, but effectiveness is not established due to numerous methodological challenges. These challenges, such as identifying empirical indicators and refining operational definitions, could be alleviated though use of an appropriate conceptual framework. DESIGN Discussion paper. DATA SOURCES In mid-April 2014, the primary author searched five electronic, scientific literature databases for conceptual frameworks applicable to study isolation precautions, without limiting searches by publication date. IMPLICATIONS FOR NURSING By reviewing promising conceptual frameworks to support isolation precautions effectiveness research, this article exemplifies the process to choose an appropriate conceptual framework for empirical research. Hence, researchers may build on these analyses to improve study design of empirical research in multiple disciplines, which may lead to improved research and practice. CONCLUSION Three frameworks were reviewed: the epidemiologic triad of disease, Donabedians healthcare quality framework and the Quality Health Outcomes model. Each has been used in nursing research to evaluate health outcomes and contains concepts relevant to nursing domains. Which framework can be most useful probably depends on whether the study question necessitates testing multiple interventions, concerns pathogen-specific characteristics and yields cross-sectional or longitudinal data. The Quality Health Outcomes model may be slightly preferred as it assumes reciprocal relationships, multi-level analysis and is sensitive to cultural inputs.

The Great American Recession and forgone healthcare: Do widened disparities between African-Americans and Whites remain?

Objective During the Great Recession in America, African-Americans opted to forgo healthcare more than other racial/ethnic groups. It is not understood whether disparities in forgone care returned to pre-recession levels. Understanding healthcare utilization patterns is important for informing subsequent efforts to decrease healthcare disparities. Therefore, we examined changes in racial disparities in forgone care before, during, and after the Great Recession. Design Data were pooled from the 2006–2013 National Health Interview Survey. Forgone medical, mental, and prescription care due to affordability were assessed among African-Americans and Whites. Time periods were classified as: pre-recession (May 2006-November 2007), early recession (December 2007-November 2008), late recession (December 2008-May 2010) and post-recession (June 2010-December 2013). Multivariable logistic regressions of race, interacted with time periods, were used to identify disparities in forgone care controlling for other demographics, health insurance coverage, and having a usual place for medical care across time periods. Adjusted Wald tests were performed to identify significant changes in disparities across time periods. Results The sample consisted of 110,746 adults. African-Americans were more likely to forgo medical care during the post- recession compared to Whites (OR = 1.16, CI = 1.06, 1.26); changes in foregone medical care disparities were significant in that they increased in the post-recession period compared to the pre-recession (OR = 1.17, CI = 1.08, 1.28 and OR = 0.89, CI = 0.77, 1.04, respectively, adjusted Wald Test p-value < 0.01). No changes in disparities were seen in prescription and mental forgone care. Conclusion A persistent increase in forgone medical care disparities existed among African-Americans compared to Whites post-Great Recession and may be a result of outstanding issues related to healthcare access, cost, and quality. While health insurance is an important component of access to care, it alone should not be expected to remove these disparities due to other financial constraints. Additional strategies are necessary to close remaining gaps in care widened by the Great Recession.

Influence of staff infection control training on infection-related quality measures in US nursing homes

HighlightsAbout half of nursing homes provide computer‐based staff infection prevention and control training.Timing of training was associated with better urinary catheter use quality measures.Evaluating the impact of nursing home staff training on infections may be warranted. &NA; Health care‐associated infections are a leading cause of morbidity and mortality in US nursing home residents. Ongoing training of nursing home staff is vital to the implementation of infection prevention and control processes. Our aim was to describe associations between methods, frequency, and timing of staff infection prevention and control training and infection‐related quality measures. In this national survey of nursing homes, timing of staff infection prevention and control training was associated with reduced indwelling urinary catheter use.