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Outbreaks in Nursing Homes

Life expectancy is continually on the rise here in the United States, however, just because

we are living longer, does not necessarily mean it is because we are getting healthier. We are

developing more treatments and learning how to identify early onset medical emergencies in

order to prevent them or treat them accordingly, but as we get older, our risk of developing more

disease processes increases for many. With each disease process or chronic medical condition

added to a resident’s medical chart, the immune system becomes weaker as it struggles to defend

the body from foreign invaders. This understanding helps us see how bacteria and viruses can

easily invade an elderly individual’s body and may cause severe effects due to their weakened

ability to fight against it. Weakened immune systems and close contact with other individuals or

objects can easily spread infectious agents from one individual to the next. Nursing homes

“provide an ideal environment for acquisition and spread of infection: susceptible residents who

share sources of air, food, water, and health care in a crowded institutional setting”, according to

Oxford University (2003). Especially with continuous visitors and staff leaving and returning to

the facility, infectious agents can easily be brought in from the outside world. Understanding

why nursing homes are prone to outbreaks and how to prevent them through infection control are

critical in maintaining resident safety as well as being aware of how nursing homes are handling

the most recent Coronavirus Disease 2019 (COVID-19) pandemic.

Nursing homes are prone to outbreaks because of the environment and hands-on care

given to every patient. Nurses and other health care personnel work closely with residents to

maintain their safety and personal well-being. Caring for each resident involves close contact

with them and with many of the resident’s belongings. Many of these objects that both residents

and health care workers come into contact with can become reservoirs for infectious agents, most
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significantly, bacteria. Bacteria is the most commonly found infection causing agent within

health care institutions. However, in order for an infectious agent to cause disease within an

individual there are some important factors that must be present. First is the concentration or

number of organisms present, secondly, the ability to cause disease known as virulence and third,

as previously mentioned, the strength of an individual’s immune system (Lynn, 533). The

transmission of these infectious agents can be either through direct transmission or indirect

transmission. Direct transmission within the nursing home can most commonly be associated

with skin to skin contact when a nurse is caring for a patient. Indirect transmission can be

through a contaminated instrument used during a procedure or by simply touching paperwork. If

health care professionals do not take necessary precautions when caring for a patient, bacteria

can be spread very easily and very quickly without anyone knowing.

For example, imagine a nursing home nurse who contracted an infectious agent while at a

grocery store. The next day, exhibiting no symptoms, he or she arrives to work and begins taking

care of their patient for the day. Depending on the resident, when receiving care from this nurse,

they may also contract the same infectious agent; this is called an exogenous infection since this

resident contracted the infectious agent from another person. This resident, now carrying the

disease, may venture out to the dining hall for meals, engage with other workers and residents

potentially infecting them, and then make their way back to their room in which they may share

with another resident, infecting them as well. That resident may also have therapy in which he or

she may be using different machines or equipment for exercise that will be shared with many

others. Without taking standard precautions when caring for patients, everyone and everything

that the nurse has interacted with could very well become reservoirs for the transmission of this

infectious agent to many others. Once infection works its way into a nursing home, it is very
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difficult to intervene and quickly stop the spread, so the faster nursing homes can intervene and

detect infection the faster they can stop the spread. Once knowing the nature of the disease,

health care professionals should be able to better alter their interventions for infection control of

the outbreak. According to the Centers for Disease Control and Prevention (CDC),

approximately one to three million serious infections occur annually in nursing homes and long-

term care facilities, most commonly being infections of the urinary tract and antibiotic-resistant

staph in addition to diarrheal diseases (2019).

The CDC has set guidelines for infection control within all health care settings including

nursing homes. The CDC has separated these guidelines into two tiers of precautions (Lynn,

550). Tier 1 consists of standard precautions implemented 24/7 regardless of patient diagnosis

and are imperative for maintaining a safe environment for everyone. Hand hygiene is the single

best way to prevent the spread of microorganisms in and outside of health care facilities and

must be followed throughout Tier 1 and Tier 2. Some scenarios of utilizing standard precautions

within the nursing home include performing hand hygiene when entering and exiting a resident’s

room, touching residents’ bed or bedside table, before and after touching a patient, before a clean

or aseptic procedure, before and after assisting with meal consumption, and wearing clean gloves

if exposed to any bodily fluids and following proper cough etiquette. Tier 2 consists of

transmission-based precautions which are defined as, “precautions used in addition to standard

precautions for patients…with suspected infection with pathogens that can be transmitted by

airborne, droplet, or contact routes” (Lynn, 550). Airborne precautions include placing patients

in negative air pressure rooms, wearing a mask or respirator when entering the patient’s room,

and transporting that patient only when absolutely necessary. Droplet precautions include

donning personal protective equipment (PPE) before entering the patient’s room and keeping all
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visitors at a distance of 3 feet from the patient. Contact precautions include donning PPE when

entering the patient’s room, avoiding sharing any equipment used with the patient, and limiting

movement out of the room.

Currently, nursing homes within the United States are following extreme droplet

precautions due to the present pandemic. According to the CDC regarding nursing homes,

“Given their congregate nature and resident population served…nursing home populations are at

the highest risk of being affected by COVID-19” (2020). COVID-19 stands for Coronavirus

Disease of 2019 and has taken the world by storm while targeting those most vulnerable to

disease processes due to their decreased immunity and underlying medical conditions. The

Coronavirus is illustrated by the CDC as an illness spreading from person to person and can

range in symptoms from mild or no symptoms to severe illness usually found in older adults with

serious underlying medical conditions (2020). Nursing homes are the prime centers to be

affected by this virus, in fact, 8 out of 10 deaths due to the coronavirus have been individuals of

65 years of age and older, and therefore workers must be very diligent and urgent when carrying

out infection control procedures (CDC, 2020).

The CDC has recommended specific instruction for infection control of COVID-19

within nursing homes. First and foremost, the CDC asks for all faculty within nursing homes, to

NOT come to work if sick. The CDC also address ways to prevent the virus from entering the

facility by restricting all visitors and volunteers non-essential to residents, requiring active

screening of anyone entering the facility for fever and other symptoms of COVID-19 and

canceling all field trips outside of the facility (2020). Health care staff should also monitor all

residents’ temperatures daily or more often if having any additional concern. Since the

Coronavirus can be spread from person-to-person when you cough, talk, or sneeze, facemasks
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are imperative to preventing the spread of your own germs. Individuals must also understand that

because many who carry the virus are asymptomatic, facemasks must also be worn by

individuals who may not think they have the virus. While wearing masks, they must cover both

an individual’s mouth and nose and should never pull the mask below the nose.

The CDC also includes important information regarding ability to identify COVID-19

infections early in residents. The elderly population infected by the virus may not show typical

symptoms of the virus like fever (more than 100 °F) or respiratory difficulty. More common

symptoms shown in older populations include new or worsening malaise, dizziness, or diarrhea

which if exhibited should follow with immediate isolation and further evaluation (CDC, 2020). It

is important to note that testing priorities in Ohio have recently been altered to prioritize all

nursing home residents and staff members regardless if they are showing symptoms or not. This

priority change will allow nursing homes to identify carriers of the virus who are asymptomatic

and help improve outbreak prevention strategies. Other CDC guidelines implemented are social

distancing of six feet for all residents with many facilities restricting residents to their rooms for

all activities and meals. Staff should also do their best to maintain their own social distancing.

Since family and friends of residents in nursing homes are currently restricted from

visiting, it is very important for health care staff inside of the facility to help each resident

maintain contact with their family and friends. This may include helping a resident make a phone

call or Facetime. For many residents, not seeing their loved ones for this prolonged indefinite

period of time can be very isolating and lonely for them. “People who find themselves

unexpectedly alone due to the death of a spouse or partner, separation from friends or family,

retirement, loss of mobility, and lack of transportation are at particular risk [for developing a

variety of physical and mental conditions]” (National Institute on Aging [NIA], 2019). We must
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keep in mind that a large percentage of residents in nursing homes are widowed or never

married. I believe it is fair to argue that more interventions may need to be put in place not just to

keep residents safe from the virus, but to maintain their health physically and mentally. For

residents to be confined to their room for a large majority of their day, their social interactions

with other residents is significantly depleted and they may begin to detach from the present.

During an interview with the NIA, Dr. Cole, a professor in medicine, psychiatry and

biobehavioral sciences at UCLA states, “Losing a sense of connection and community changes a

person’s perception of the world” (2019). This is particularly concerning for those individuals

with cognitive impairment being isolated from their loved ones during the COVID-19 pandemic.

Dr. Cole adds that “people who feel lonely may also have weakened immune cells that have

trouble fighting off viruses, which makes them more vulnerable to some infectious diseases”

(NIA, 2019). Nurses and other health care workers can help these residents by providing

engaging activities to perform within their rooms, taking leisurely strolls outside with residents

for fresh air, checking in on patients more often, helping residents connect with their loved ones

via phone calls or Facetime calls, and many more. Some facilities are allowing loved ones to see

residents through windows. Contacting residents’ families for photos of loved ones is a great

way for residents to pass the time by looking through photos and helping work their memory.

During this pandemic, we all must be creative with our time and on the lookout to help others

while maintaining a safe environment.

In conclusion, understanding why nursing homes are vulnerable to have outbreaks will

help health care workers make the best intervention decisions and infection control procedures to

ensure resident safety both mentally and physically. During these unprecedented times, the

public is depending on health care workers to keep their at-risk loved ones safe and healthy from
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the Coronavirus. However, the public must also do their part to keep health care workers safe

which in return will help our nursing home residents. Infection control procedures are being put

to action and nursing homes are doing every bit that they can to keep their staff and residents

healthy and free from this virus among many other diseases. Maintaining proper hand hygiene,

having available PPE and social distancing will aid in the prevention of COVID-19 outbreaks in

nursing homes. During these times, health care personnel must go the extra mile in caring for

their patients by providing any connections to their loved ones as possible. Even one call can

make the world of a difference. Our mindset will determine our attitude when handling

situations. Whether a nurse or a resident or a family or friend, everyone must stay connected and

perform all necessary precautions to prevent the spread of the coronavirus and any other diseases

calling for infection control procedure. Stop the spread and start the healing.

Citation

Centers for Disease Control and Prevention. (2019). Nursing Homes and Assisted Living (Long

-term Care Facilities [LTCFs]). Retrieved from

https://www.cdc.gov/longtermcare/index.html

Centers for Disease Control and Prevention. (2020). Key Strategies to Prepare for COVID-19 in

Long-term Care Facilities (LTCFs). Retrieved from

https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html

Centers for Disease Control and Prevention. (2020). Older Adults. Retrieved from

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
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Centers for Disease Control and Prevention. (2020). Preparing for COVID-19: Long-term Care

Facilities, Nursing Homes. Retrieved from https://www.cdc.gov/coronavirus/2019-

ncov/hcp/long-term-care.html

Centers for Disease Control and Prevention. (2020). What you should know about COVID-19 to

protect yourself and other. Retrieved from

https://www.cdc.gov/coronavirus/2019-ncov/downloads/2019-ncov-factsheet.pdf

High, K., Joseph, C., Strausbaugh, L., Sukumar, S. (2003, April 1). Infectious Disease

Outbreaks in Nursing Homes: An Unappreciated Hazard for Frail Elderly Persons.

Oxford Academic. https://academic.oup.com/cid/article/36/7/870/318878

Lynn, T.L. (2015). Fundamentals of Nursing: The art and science of person-centered nursing

care. (8th ed.). L. McAllister.

Myers, J. (2020, April 27). Coronavirus: Ohio changes priority testing guidelines as nursing

homes race to identify asymptomatic carriers. The Columbus Dispatch. Retrieved May

3, 2020, from https://www.dispatch.com/news/20200426/coronavirus-ohio-changes-

priority-testing-guidelines-as-nursing-homes-race-to-identify-asymptomatic-carriers

Nursing Homes. (n.d.). HealthinAging. Retrieved May 3, 2020, from

https://www.healthinaging.org/age-friendly-healthcare-you/care-settings/nursing-homes
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Social isolation, loneliness in older people pose health risks. (2019, April 23). National

Institute on Aging. https://www.nia.nih.gov/news/social-isolation-loneliness-older-

people-pose-health-risks