Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19

This tool is an update to the previous ICAR tool for nursing homes preparing for COVID-19. Notable changes as of November 20, 2020 include:

• Additions to reflect updated guidance such as SARS-CoV-2 testing in nursing homes
• Increased emphasis on the review of Personal Protective Equipment (PPE) use and handling
• Addition of sections to help guide a video tour as part of a remote TeleICAR assessment or in-person tour of a nursing home
• Addition of an accompanying facilitator guide to aide with the conduction of the ICAR and create subsequent recommendations for the facility

This updated ICAR tool is a longer but more comprehensive assessment of infection control practices within nursing homes. Due to the addition of example recommendations to aid the facilitator during the process of conducting an ICAR, the facilitator guide version of the tool appears even longer. Facilitators may decide whether to use the tool in its entirety or select among the pool of questions that best fit their jurisdictional needs and priorities as part of quality improvement efforts.

In-person versus remote ICAR

The decision to conduct an assessment in-person or remotely via a TeleICAR depends upon several factors, such as available public health resources, the location and remoteness of the facility, and the presence of an active outbreak. For facilities with recent cases of SARS-CoV-2 infection in healthcare personnel or residents, an in-person assessment is preferred; however, jurisdictions must individually determine how to best provide assistance in the timeliest manner.

In-person ICARs:

• are preferred whenever possible, especially for facilities experiencing an outbreak
• are not prone to the same technical limitations (e.g., video function failure) that may limit the conducting of a remote ICAR
• typically allow the facilitator performing the ICAR to visualize more of the facility’s IPC practices

Remote TeleICAR assessments:

• allow for a larger number of facilities to be reached in a shorter amount of time
• allow for social distancing
• are unlikely to identify as many gaps in practices as in-persons visits, even with the addition of the video component

The decision to conduct an assessment in-person or remotely via a TeleICAR depends upon several factors, such as available public health resources, the location and remoteness of the facility, and the presence of an active outbreak. For facilities with recent cases of SARS-CoV-2 infection in healthcare personnel or residents, an in-person assessment is preferred; however, jurisdictions must individually determine how to best provide assistance in the timeliest manner.

Steps to an ICAR

Whether conducting an ICAR in person or remotely (i.e., TeleICAR), the steps to the ICAR process are similar. In most instances it involves, scheduling the ICAR, conducting the ICAR with the preconstructed tool to guide the assessment, providing both verbal and written feedback to the facility, and then following-up on how the facility is implementing the suggested improvements. More information on these steps can be found in the Frequently Asked Questions.

How to use this ICAR tool

This tool is intended to help assess IPC practices for nursing homes without an active outbreak of COVID-19. However, public health jurisdictions may choose to modify this tool to fit their needs beyond this defined scope. For example, jurisdictions may choose to modify the tool to assess facilities experiencing an outbreak. While many of the concepts covered in this tool should be reviewed regardless of outbreak status (e.g., PPE use, hand hygiene, environmental cleaning, etc.), some areas may require more in-depth review such as current outbreak epidemiology (e.g., affected units, number of exposed HCP and residents, etc.), resident cohorting strategies, facility management of symptomatic or exposed residents, testing strategies, and mitigating staffing shortages. In addition, the video or in-person tour should dedicate more time to observing IPC practices in the designated COVID-19 area.

The tool is available in both a facilitator guide and a non-facilitator guide format.

• The facilitator guide format contains a side-by-side layout of both the question and answer choices as well as the recommended IPC practice(s) based upon current CDC guidance. By having ready access to the recommend practice(s), the facilitator may provide immediate verbal feedback and recommendations to the facility during the assessment.
• The non-facilitator guide format only contains the question and answer choices.

Most ICARs, whether remote or in-person, begin with a discussion of current IPC policies and practices. Following this discussion, a facility tour can assess how the facility is implementing many of these discussed strategies. If the ICAR can only be conducted remotely, the assessment facilitator should include a video tour whenever possible.

The tool is divided into fourteen sections:

Section 1: Collects facility demographics and critical infrastructure information and is intended for completion by the facility prior to the ICAR (provided as separate PDF to send to facility, Section 1: Demographics and Critical Infrastructure pdf icon[424 KB, 4 Pages]. These questions are often ones that require the facility to look up or consult with certain staff members and thus pre-collection often saves times during the actual assessment. The ICAR facilitator should decide if any of the responses need to be verbally reviewed or require further explanation at the beginning of the assessment. If no further clarification is needed, then the facilitator should start on the next section and refer back to this section as needed.

Section 1 of the facilitator guide provides the rationale behind the questions, and how the answers may be utilized during the rest of assessment.

Sections 2-7: Are intended for review during a discussion of policies and practices with the facility. These sections cover personal protective equipment (PPE), hand hygiene, environmental cleaning, general IPC practices, resident-specific practices, and SARS-CoV-2 testing.

The questions are formatted to include:

• Scenarios such as what type of PPE would be used in certain situations,
• Closed-ended questions with “yes/no” response options, and,
• Open-ended questions which prompt for more descriptive responses
  • For the open-ended questions, common responses are often listed below each question to aid in response collection but may contain answers that would not be considered a recommended IPC practice. The facilitator guide should be consulted for the recommended IPC practice.

Sections 8-14: Are intended for use during an in-person or video tour of the facility and include a review of screening areas, hand hygiene supplies, PPE use and storage, frontline HCP interviews, and breakrooms, and a designated COVID-19 care area. These sections are meant to assess how some of the discussed policies and practices are being implemented. If this tool is being used as part of an in-person assessment, additional areas and observations of HCP practices can be assessed beyond what is listed in this tool. The facilitator guide provides some additional instructions for use of these sections.

This tool to include the facilitator guide will be updated as nursing home guidance is updated. Please check back routinely following guidance updates to access the most current tool.

The TeleICAR team within the Division of Healthcare Quality Promotion can provide training to public health jurisdictions on the use of the tool to include TeleICAR demonstrations with facilities. A Frequently Asked Questions document regarding TeleICAR remote assistance is also available. For more information contact, [email protected].