The Dirty Little Secret of Nursing Homes

by | Sep 28, 2012

This sounds like common sense: If you work in a nursing home, you wash your hands when you start your shift and again before you leave. You wash your hands (or, in some cases, use an alcohol-based antimicrobial) before and after any direct contact with residents. Before you help someone with tooth-brushing, bathing, eating or using the toilet. Before and after handling a catheter or taking a finger-stick blood sample or changing a dressing. Or handling used bed linens. Or blowing your own nose.

In fact, these are not only common-sensical habits; they’re prescribed by guidelines from the Centers for Medicare and Medicaid, part of the process by which the nation’s nursing homes are inspected and certified.

Yet the percentage of nursing homes cited for deficiencies in “hand hygiene” has been rising in recent years. Inspectors found such deficiencies in fewer than 7.4 percent of nursing homes from 2000 to 2002, but by 2009 found them in close to 12 percent. Some states did better: Hand hygiene citations in Pennsylvania in 2009 came from just 6 percent of facilities. Some fared much worse: Michigan that year was at 15 percent.

One reason cited by the University of Pittsburgh gerontologist Nicholas Castle, a veteran nursing home researcher whose team uncovered this trend, was the growing emphasis on infection control, which means that “surveyors are probably looking harder than they used to” — not a bad thing.

But the study, published in the Journal of Applied Gerontology, also indicated that understaffing and insufficient training played a part. “Most facilities understand the importance of hand washing,” Dr. Castle said in an interview. “It’s a question of having the staff and resources to implement what they know they should be doing.”

In an era when fierce infections like MRSA and Clostridium difficile haunt nursing homes and hospitals (patients in one often become patients in the other, and around again), this represents a dispiriting trend. Usually very elderly, and sick and frail almost by definition, nursing home residents are particularly vulnerable to infection. Infections picked up in health care settings represent their single greatest cause of sickness and death, the reason underlying a quarter of all hospitalizations from long-term care facilities.

So why the decline in hand washing? Dr. Castle’s analysis of Medicare data points to staff members that are stretched thin: hand hygiene deficiencies show up significantly more often in nursing homes with proportionately fewer nurses, both R.N.s and L.P.N.’s, and aides. Facilities where many residents need a more hands-on help, or have dementia, have more hand-washing lapses, too.

But external factors also come into play: Nursing homes in states with lower Medicaid reimbursement rates, for example, are significantly more likely to be cited for hand hygiene deficiencies.

The real rate of unwashed hands may actually be higher than the data shows, Dr. Castle added. When would staffers be more likely to comply with Medicare guidelines than when inspectors are prowling the halls with clipboards and checklists? “You’d think they’d be on their best behavior,” he said.

You would also think the most direct route to improvement would be to add more staff and raise Medicaid reimbursements for nursing homes. But in the current economic and governmental climate, Dr. Castle noted, “they’re unlikely to get either and they have to do more with less,” which may be the most dispiriting element of all.

Still, he pointed out, “many facilities do get this right,” even though aides may have to wash their hands 100 times or more each workday. The Centers for Disease Control and other organizations provide educational materials and training programs, and management approaches should probably also play a role.

His team’s next study will look at how nursing homes without hand-washing deficiencies — the great majority — pull that off.

In the interim, staff members aren’t the only source of infections entering (or leaving) nursing homes and threatening residents’ well-being. When you and your family visit, wash your hands.


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