Remote infection control assessments in long-term care facilities during COVID-19 pandemic in Texas, 2020

The Texas Department of State Health Services (DSHS) Healthcare Safety Unit (HCSU) conducts remote infection control assessments (tele-ICARs) in long-term care facilities (LTCFs) to evaluate COVID-19 infection prevention and control (IPC) knowledge and practices using a standardized assessment tool. Tele-ICARs are used to gauge different IPC measures specific to SARS-CoV-2 and are either proactive--conducted prior to identified cases--or responsive to an outbreak, which is defined as a new SARS-CoV-2 infection in any staff or any facility-onset infection in a resident. State and local partners use findings from the assessments to aid LTCFs by providing targeted and timely resources and support to mitigate identified gaps.

Data from tele-ICARs conducted between March 1 and October 30, 2020 were analyzed to assess major gaps across LTCF types. A major gap was defined as 10% or more of facilities not satisfying a specific IPC measure, excluding missing data. Gaps were also assessed by tele-ICAR type: proactive or responsive. Fisher's exact tests and univariate logistic regression were used to characterize significant associations between major IPC gaps and LTCF or tele-ICAR type.

DSHS conducted tele-ICARs in 438 LTCFs in Texas during 8 months; 191 were nursing homes/skilled nursing facilities (NH/SNFs), 206 were assisted living facilities (ALFs) and 41 were other settings. Of the assessments, 264 were proactive and 174 responsive. Major gaps identified were: (1) 22% did not have a preference for alcohol-based hand sanitizer (ABHS) over soap and water; (2) 18.1% were not aware of the contact time for disinfectants in use; (3) 17.9% had not stopped resident communal dining; (4) 16.8% did not audit hand hygiene and PPE compliance; and (5) 11.8% had not stopped inter-facility group activities and extra-facility field trips. When restricting analyses to proactive tele-ICARs, one additional gap was identified: 11.1% of facilities lacked a dedicated space to care for or cohort residents with confirmed SARS-CoV-2 infection. Significantly more ALFs than NH/SNFs had not suspended resident communal dining (P < .001) nor identified a dedicated space to cohort residents with confirmed SARS-CoV-2 infection (P < .001). Significantly more LTCFs that received a responsive ICAR compared to a proactive ICAR reported a preference for ABHS over soap and water (P = .008) and reported suspending communal dining (P < .001) and group activities (P < .001). Also, significantly more LTCFs that received a responsive ICAR compared to a proactive ICAR had identified a dedicated space to cohort residents with confirmed SARS-CoV-2 (P = .009).

Increased facility education and awareness of federal and state guidelines for group activities and communal dining is warranted in Texas, emphasizing the importance of social distancing for preventing the transmission of SARS-CoV-2 in LTCFs, particularly ALFs. CDC recommendations for ABHS versus hand washing should be emphasized, as well as the importance of monitoring and auditing HCP hand hygiene and PPE compliance. Facilities may benefit from additional education and resources about disinfection, to ensure proper selection of disinfectants and understanding of the contact time required for efficacy. Analysis by tele-ICAR type suggests facilities may benefit from identifying space for dedicated COVID-19 units in advance of an outbreak in their facility. Conducting tele-ICARs in LTCFs enables public health agencies to provide direct and individualized feedback to facilities and identify state-wide opportunities for effective interventions in response to SARS-CoV-2.