Nursing homes and long-term care facilities may be infection ‘cauldrons’

candidaauris-300x224The battle to reduce the sky-high cost of hospital care may have created its own unforeseen and harmful consequence: By hastening to get patients out of traditional hospitals and into skilled nursing facilities and long-term care centers, doctors and policy-makers may be contributing to a medical nightmare — serious infections acquired in health care institutions.

The New York Times reported that “public health experts say that nursing facilities, and long-term hospitals, are a dangerously weak link in the health care system, often understaffed and ill-equipped to enforce rigorous infection control, yet continuously cycling infected patients, or those who carry the germ, into hospitals and back again.”

Hospital-acquired infections (HAIs) pose significant risks to already ill and injured patients, as well as adding to the fearsome costs of institutional care, the Leapfrog Group, an independent patient safety and advocacy group has found. As Leapfrog has reported:

“[O]ne out of 25 patients in U.S. hospitals contracts [HAIs]. These infections can significantly delay recovery, increase the expense of a hospital stay, and even result in death. Of the approximately two million American patients who acquire an HAI annually, an estimated 90,000 will die … The cost of a single case can range from just under $1,000 to nearly $50,004, depending upon the type of infection — with the direct cost of HAIs to hospitals estimated at between $28 billion and $45 billion. These costs are passed along to insurers and employers, as well as to patients themselves in the form of higher out-of-pocket costs.”

Hospitals and academic medical centers, however, cannot get HAIs better under control if skilled nursing facilities (aka SNFs or “Sniffs”) and acute-care centers incubate, intensify, and spread infections. This is a growing peril, the New York Times reported, because antibiotic-resistant bugs are teeming and flourishing in SNFs and long-term, acute-care hospitals.

Betsy McCaughey, a former lieutenant governor of New York who leads the nonprofit Committee to Reduce Infection Deaths, told the newspaper that the non-hospital treatment facilities “are cauldrons that are constantly seeding and reseeding hospitals with increasingly dangerous bacteria. You’ll never protect hospital patients until the nursing homes are forced to clean up.”

The newspaper, which also described the patient suffering that the infections cause, reported this:

“The story is far bigger than one nursing home or one germ. Drug-resistant germs of all types thrive in such settings where severely ill and ventilated patients … are prone to infection and often take multiple antibiotics, which can spur drug resistance. Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public because of lax hygiene and poor staffing. These issues have also vexed long-term, acute-care hospitals, where patients typically stay for a month or less before going to a skilled nursing home or a different facility.”

Reporters Matt Richtel and Andrew Jacobs followed patients and families, notably as they expressed their anger and frustration at how poorly staff at SNFs and acute-care facilities deal with antibiotic-resistant infections, including Candida Auris. It is a drug-resistant fungus that is spreading globally, causing great concern because this “superbug” preys on patients who already are hospitalized and may have compromised immune systems. The reporters said they saw care givers go in and out of infected patients’ rooms without basic safeguards, like gloves, gowns, and masks. Family members also told them that they don’t see custodial workers at the facilities cleaning and sanitizing rooms and the facilities as they must to battle HAIs, much less stubborn antibiotic-resistant infections.

For patients and families, whatever hope they might get from advancing treatments that can sustain and extend lives, notably by the breathing assistance of ventilation, may sapped by the exhausting, depressing, and agonizing cycling that the sick, injured, and infected experience. It is little wonder that the New York Times, separately, reported on a study about patients’ poor prospects with ventilation, writing:

“Only a quarter of intubated patients go home from the hospital. Most survivors, 63%, go elsewhere, presumably to nursing facilities. The study doesn’t address whether they face short rehab stays or become permanent residents. But it does document the crucial role that age plays. After intubation, 31% of patients ages 65 to 74 survive the hospitalization and return home. But for 80- to 84-year-olds, that figure drops to 19%; for those over age 90, it slides to 14%. At the same time, the mortality rate climbs sharply, to 50% in the eldest cohort from 29% in the youngest.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones nursing home abuse and neglect. Elder care can be complex, challenging, and it may have limits on its successful outcomes due to the weakened and frail condition of its charges.

It is costly, with a private room in a nursing home running on average in excess of $100,000 annually. That said, operators of the facilities have gotten ripped for skimping on the number, training, and skills of care givers in their homes. Reports occur too often of short staffing, shoddy, and abusive nursing home care and the need for regulators of the facilities to step up their oversight of them in urgent and intensive fashion.

The New York Times reported that long-term, acute-care facilities also are booming, costly, and not without their own quality and safety challenges:

“Neale Mahoney, an economist at the University of Chicago who studies the industry’s growth, [reported that there] are now about 400 long-term care hospitals across the country, up from about 40 in the early 1980s, he said. Since 2012, the number of skilled nursing homes with ventilator units rose to 436 from 367 — a significant jump but still a fraction of the nation’s 15,000 nursing homes … ‘Ventilator units are the poster child, the best example of a place that has challenges,’ said Dr. Alexander Kallen, an [infections] outbreak expert …The federal government reimburses facilities for ventilator patients at significantly higher rates than for other patients … Ventilated patients can bring in $531 a day compared to $200 for a standard patient. That’s about $16,000 a month compared to $6,000. The reimbursement rates reflect the significant care required for vulnerable patients, and the cost of equipment. [The federal government] contends the majority of skilled nursing homes do well with staffing and overall care. Yet roughly 1,400 nursing homes received a one-star rating for staffing in 2018 from the agency.”

This is not good, especially in our rapidly graying nation, where 10,000 baby boomers each day turn age 65 and this reality for this giant population group will keep going until 2030, demographers estimate.

It’s a sound idea to deal with unacceptable, soaring hospital costs by encouraging institutions to not keep patients in beds just to increase profits. At the same time, it defies common sense to boot the sick and injured to facilities that may hold them — and worsen their condition. The New York Times, separately, has posted a piece on long-term acute-care hospitals, emphasizing their grim outcomes overall for older patients especially, frail and sick individuals who might better be served by hospice care. And, incidentally, did I mention that because many of the affected patients are elderly, we taxpayers foot the bill (via Medicare) for this cycle of bad care? We all have big interests in improving the quality and safety of hospitals, skilled nursing facilities, long-term and acute-care hospitals, and nursing homes. We all have lots of work to do.

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