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This guidance document updates the 2008 Society for Healthcare Epidemiology of America (SHEA)/Association for Professionals in Infection Control and Epidemiology (APIC) guideline: Infection Prevention and Control in the Long-Term Care Facility and is intended to assist nursing homes in the United States (US) in defining and implementing their infection prevention and control (IPC) programs and practices.

Nursing homes, also called skilled nursing facilities, are an important provider of healthcare in the United States. The 2008 SHEA/APIC guideline provided a framework to define the structure and main elements for implementing a nursing home IPC program. The common infections occurring in nursing home residents and the viral and bacterial pathogens causing outbreaks in nursing homes described in that guidance remain quite relevant today. Furthermore, as seen during the COVID-19 pandemic, nursing home residents and healthcare personnel (HCP) experienced significant morbidity from outbreaks of SARS-CoV-2 introduced when virus was circulating in the community. While the basic principles for implementing a nursing home IPC program remain the same, facilities are challenged by the tasks of ensuring their IPC program’s infrastructure and practices evolve to meet the changing care needs of their resident population and responding to the emergence of antimicrobial resistance and novel pathogens. The Centers for Medicare and Medicaid Services (CMS) has made IPC in nursing homes a priority. Additionally, nursing homes must be attentive to and ready to adapt to changing recommendations by the Centers for Disease Control and Prevention (CDC) and standards by regulatory agencies.

The medical complexity and acuity of care provided in nursing homes has continued to significantly increase. Most individuals admitted to nursing homes come directly from acute care hospitals for the provision of skilled nursing or rehabilitative services, rather than primary residential care. These post-acute care residents experience risks of healthcare-associated infections and colonization with multidrug-resistant organisms (MDROs), such as exposure to indwelling medical devices, use of intravenous therapy, especially antibiotics, and presence of wounds, that are similar to those for hospitalized patients. , In addition, a growing number of nursing homes have expanded their services to include specialty units for ventilator-dependent residents, further increasing the medical complexity and the risk of infection and MDRO colonization. ,

A key component to reducing risks for nursing home residents, especially among those who require higher acuity care, is the incorporation of core IPC practices (e.g., hand hygiene, Standard Precautions, cleaning and disinfection of equipment) during resident care activities. Residents, HCP, and visitors may worry that IPC measures, including the placement of supplies and resources in resident rooms and care areas, will undermine attempts to maintain a “home-like environment” for residents. Additionally, prolonged restrictions on in-person visitation during the COVID-19 pandemic likely contributed to reductions in the physical and psychological well-being of the residents. However, IPC measures taken to provide safe care and reduce the spread of infectious pathogens are critically important to maintaining a resident’s health and quality of life. Nursing homes should support a culture that prioritizes safety and emphasizes that everyone has a role in promoting infection prevention. Successful strategies include engaging frontline HCP in identifying solutions to ensure IPC practices during resident care, creating a culture of shared accountability for IPC outcomes, educating residents and their families, and supporting the use of innovative IPC improvement activities.

Since the early 1990s, CMS regulatory standards for nursing homes have required nursing homes to have IPC programs. The effectiveness of these requirements has been variable, with lapses of IPC practice remaining among the most commonly cited deficiencies in US nursing homes from 2000 to 2007. In 2016, nursing home regulations underwent substantial updates, including new requirements for nursing home IPC programs that included implementing new antimicrobial stewardship activities and designating an infection preventionist with specialized training in IPC to be responsible for the IPC program. An evaluation of IPC programs comparing nursing home survey data from 2014 and 2018 showed promising improvements in implementation of specific IPC practices following the release of the new regulations ; however, the regulatory assessments of IPC programs in nursing homes across the country remain variable, raising concerns about the consistency and effectiveness of oversight from state to state.

In the midst of the changing clinical landscape and growing regulatory expectations for nursing home IPC programs, a proposal was made to update the 2008 SHEA/APIC guideline: Infection Prevention and Control in the Long-Term Care Facility in order to support nursing homes’ IPC programs and implementation of practices based on a review of currently available evidence, taking into consideration the unique population and type of care performed in these facilities.

Although there is a broad spectrum of post-acute and long-term care providers, including long-term acute care hospitals, home health agencies, residential care facilities, and group homes, the primary audience for this guidance are leaders of IPC programs in US nursing homes. The principles outlined in this guidance could be applicable to other residential care settings, such as assisted living communities or intermediate care facilities; however, there may be unique considerations for the needs of individuals served by or the knowledge and experience of those working in those care environments that should inform the implementation of an IPC program’s activities. No guideline or expert guidance document can anticipate all clinical situations, and this guidance document is not meant to be a substitute for individual clinical judgment by qualified professionals.

This guidance follows the process outlined in the 2017 “Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents.” While updated in September 2024, the guidance followed the 2017 Handbook until completion. IPC in nursing homes was among topics that were proposed and selected by the SHEA Guidelines Committee (GLC). The subsequent manuscript proposal developed by the GLC was approved by the SHEA Publications Committee and the SHEA Board of Trustees. SHEA develops expert guidance documents for topics important in the provision of safe, effective healthcare, but that lack the level of evidence required for a formal guideline developed using the Grading of Recommendations Assessment, Development and Evaluation or a similar systematic methodology. Expert guidance documents are based on synthesis of available evidence, theoretical rationale, current practices, practical considerations, writing group opinion, and consideration of potential harm where applicable. As such, evidence level is not provided for individual recommendations.

The writing panel developed PICO-style (population, intervention, control, and outcomes) questions based on themes that they identified. These questions were used in the development of search terms (medical subject heading and text word) by a professional medical librarian. Both the questions and search terms were voted on by the panel until unanimous approval was achieved. Articles published from January 1, 2007, through December 31, 2021, were collected from PubMed, with the search run on May 14, 2021. Articles published from 1974 through May 17, 2021, were collected from Embase, with the search run on May 18, 2021. In January 2024, the PubMed search was rerun with updated dates to January 18, 2024. Only English-language articles on human subjects were included. The abstract management software Covidence was used, and abstracts from the article yield were blindly screened by two authors for inclusion. Drs. Mody and Murthy resolved conflicts, and subgroups screened full texts of studies for inclusion in this document. SHEA guidance documents are developed with a formalized process for reaching consensus (see Supplementary Material, Table 1 for a summary list of expert guidance recommendations and Supplementary Material, Table 7 for a quick reference for topics).

Consensus around recommendations and rationale is determined via an anonymous comment period. For this document’s recommendations, full consensus was achieved. See Supplementary Material, Table 2 for a list of terminology and acronyms. See Supplementary Material, Table 3 for additional resources to support nursing home infection prevention and antimicrobial stewardship efforts. Supplementary Material, Table 8 provides the search strategy, exclusion criteria, and PRISMA.

The authors include current and past members of the SHEA Guidelines Committee, the SHEA Long-Term Care Special Interest Group, the American Geriatrics Society (AGS), and the Pediatric Infectious Diseases Society (PIDS), as well as representatives for APIC, the Post-Acute and Long-Term Care Medical Association (PALTmed; previously The Society of Post-Acute and Long-Term Care Medicine [AMDA]), and the Infectious Diseases Society of America (IDSA). Dr. Robin Jump served as an author and representative for PALTmed, Deborah Burdsall and Patricia Stone served as authors and representatives for APIC, Dr. Suzanne Bradley served as an author and representative for IDSA. All authors served as volunteers. All authors participated in the development of and attested to agreement with the recommendations and rationale sections contained in this document.

The document was reviewed by the SHEA Guidelines Committee, the SHEA Publications Committee, APIC, IDSA, PALTmed, and AGS, and endorsed by the SHEA Board of Trustees, APIC, IDSA, PALTmed, and AGS.

1. What resources (physical, human, financial) are needed to meet the goals of the nursing home’s IPC program? Recommendation: The resources for a nursing home’s IPC program should include: At least one infection preventionist (IP) to manage the infection prevention and control (IPC) program who: Has ongoing, specialized training in IPC that is financially supported by the nursing home Demonstrates commitment to ongoing continuing education in IPC to remain current in developments and strategies to optimize the IPC program Has clinical and/or public health experience Is an effective communicator, educator, leader, mentor, and collaborator Receives training in leading and managing programs Sufficient dedicated time for the IP(s) to manage the IPC program based on the complexity of the resident population and services provided: At least one full-time equivalent (FTE) IP, if the facility has more than 100 licensed beds or provides onsite ventilator or hemodialysis services At least 0.5 FTE IP (20 IP hours per week), if the facility has fewer than 100 beds and does not provide on-site ventilator or hemodialysis services Adequate staffing (e.g., nursing, clinical) and supplies (e.g., personal protective equipment [PPE], alcohol-based hand sanitizer [ABHS], US Environmental Protection Agency (EPA)-registered disinfectants) to allow healthcare personnel (HCP) to follow all recommended IPC practices

Dedicated time for personnel to receive regular job-specific IPC education and demonstrate competency through assessment (see 14 and 15 ) Access to information technology training and infrastructure (e.g., integrated electronic health records, software applications, internet access) to support facility-level surveillance activities and access to public health surveillance programs Access to expert advice, learning collaboratives, and professional associations specific to IPC (see 6, 9, and 42 ). Rationale: In 2016, the Code of Federal Regulations (483.80) required that all Centers for Medicare and Medicaid Services (CMS)-certified nursing homes have a designated person overseeing the IPC program. This person should be an IP with a scope of practice that includes IPC knowledge and skills and clear expectations to implement best practices. Although these practices should be tailored to the population and resources, they should also be built on core IPC practices outlined in CDC guidance and should be adherent to CMS requirements.

The individual overseeing the IPC program should have dedicated support from nursing home administrative and medical leadership, including the medical director, and the organization’s commitment to provide the financial resources to meet the growing scope of the IPC program. Program responsibilities include developing policies and procedures to implement the most current, evidence-based practices, using electronic systems for infection surveillance and reporting, informing HCP IPC training, auditing IPC practices, guiding outbreak preparedness, prevention, and response, promoting antimicrobial stewardship, participating in quality assurance activities, and leading quality improvement projects to improve IPC practices.

Although no recent studies are available that quantify IP hours for all levels of nursing home care, a nursing home should provide adequate IPC personnel, time, and resources in accordance with the level of acuity and services provided to residents. For example, chronically ventilated nursing home residents are at greater risk for infection. Bundled interventions (a defined set of evidence-based practices) put in place by the IP may decrease rates of ventilator-associated pneumonia. , Residents who are ventilated are at risk for high rates of MDRO colonization and may benefit from admission screening to assist with early identification and appropriate isolation, especially with the emergence of Candida auris and carbapenem-resistant Acinetobacter baumannii in nursing homes that provide ventilator services. ,–

Of note, specific staffing requirements for IPs may vary depending on the size and complexity of the facility, as well as the local and state regulations. The National Academies of Sciences, Engineering, and Medicine have recommended that the IP have sufficient time to perform required duties; one survey found approximately 25% of IP time is spent on infection surveillance. Submitting surveillance data to a network, which allowed for comparing infection rates across facilities and tracking performance improvement, has been associated with a decreased rate of healthcare-associated infections (HAIs), including influenza-like illness, urinary tract infections (UTIs), and pneumonia over time. This important and time-intensive responsibility is one of numerous responsibilities, including the IP’s engagement in continuing education and need to train and educate nursing home personnel in IPC.

As part of guidance issued during the COVID-19 pandemic, CDC recommended at least one full-time IP for every 100 beds or for any nursing home that provides dialysis or mechanical ventilation. Some states legislate FTE IPs for each nursing home. In New Jersey, nursing homes with 100 residents or more must have a full-time IP in a manager position and each nursing home must have an IPC committee. California has legislated that each nursing home must have a full-time IP. In light of the evolving expectations for nursing home IPC programs and the increasing complexity of the resident population, nursing homes larger than 100 licensed beds and those that provide onsite ventilator or hemodialysis services should have at least one FTE IP. If a facility has fewer than 100 beds or does not provide these services, a nursing home should have at least 0.5 FTE IP.

IPs who work in nursing homes should have specialized training in infection prevention and control. A national survey of US nursing homes found that facilities that have IPs with specialized IPC training (certification in infection control, state or local training course with certificate, national or local training course through a professional society, or other) were more likely to have recommended IPC policies in place, when controlling for other known measures of quality (e.g., ownership, staffing). Agarwal and colleagues also found a positive association between nursing homes that employ trained IPs who have certifications and nursing homes having a comprehensive antimicrobial stewardship program. Prior to the CMS regulation for IPC, Wagner and colleagues did not find a specific correlation between IPC training and nursing home quality measures. However, this correlation could strengthen as more directed training and efforts to build a foundation for IPC in the nursing home occurs. This group did find that having a FTE IP was associated with better outcomes in 3 of 8 quality measures (percent high-risk residents with pressure ulcers, percent influenza vaccination for long-stay residents, and percent influenza vaccination for short-stay residents).

The National Academies of Sciences, Engineering, and Medicine recommends that every nursing home has an IP who is a registered nurse (RN), advanced practice RN, or a physician and must have received specialized IPC education. However, other research has found that the effect of specialized training was not dependent on whether the IP was a RN. Therefore, since many IPs come from public health and other clinical backgrounds, the IP position does not need to be limited to only a RN or physician.

A business case should be used as a tool to support advocating to nursing home leadership for resources. , For IPC programs to be successful, the nursing home should have adequate IP and nurse staffing to reduce rates of infections, which often requires programs to improve retention of personnel. The nursing home should ensure that ample quantity of IPC supplies (e.g., PPE, ABHS, EPA-registered disinfectants) is available in resident care areas to allow HCP to follow all recommended IPC practices. The IP also needs access to information technology training and infrastructure (e.g., integrated electronic health records, software applications, internet access) to support collection and management of infection surveillance and other resident outcome data used to inform performance improvement. ,– Technologic resources not only support data collection and management within the facility but also support a nursing home’s access and connectivity to regional population and laboratory-based public health surveillance programs. – 2. To whom should the nursing home IP report? The nursing home IP should report to a designated person in administrative and medical leadership who has knowledge relevant to regulatory and resource needs for the IPC program.

The IP should be a member of the Quality Assessment and Assurance (QAA) committee to integrate IPC activities within the quality assessment and performance improvement programs. To be successful, IPC programs require visible and tangible support from all levels of nursing home personnel: Administrative and medical leadership, including the medical director, should actively participate in IPC program activities to provide appropriate resources and training to support the implementation of IPC policies and procedures Nursing homes should clearly define the IP position and include dedicated time for the IP in IPC training, continuous education, and modes of communication with facility personnel, including leadership Nursing homes should evaluate IPC program surveillance reports and practices using the Quality Assurance Performance Improvement (QAPI) process.

The nursing home should ensure that there is structured oversight of the IPC program with support for activities from administrative and medical leadership, including the medical director. Administrative leaders should provide financial resources to meet the training and continuing education needs of the IP and to procure supplies needed to implement IPC program activities. Medical leadership, including the medical director, should provide clinical insight into protocols, processes, and treatment needs and should be an active participant in the IPC program and regularly attend its meetings. ,

Reporting structures for the IPC program and the ways that administrative and medical leadership engage may vary depending on the facility’s needs. In a review article, Montoya and colleagues suggested that facilities designate an administrator to be an active part of the team led by an IP. In a qualitative study conducted in Canada during the COVID-19 pandemic, Yau and colleagues found that communication and coordination among leadership and personnel were essential to manage pandemic needs, in some instances involving daily huddles. In a successful model described by Bartels and colleagues, the nursing home IP reported to a regional director of infection prevention in a large healthcare system. With growing numbers of nursing home corporations, when available, IPC or quality leaders at the regional or national level of an organization should support and collaborate with nursing home IPs to develop standardized policies and practices. Regardless of configuration, the IP and IPC program should have a reporting structure that facilitates communication with the medical director and leadership of relevant departments, including mechanisms to seek resources for the IPC program.

In the United States, CMS requires that each nursing home facility maintain a QAA committee that meets at least quarterly and includes the director of nursing, the medical director or designee, at least three other staff members (one of whom must be in a leadership role), and the IP. , CMS also requires that each facility conduct an annual review of the IPC program and update the program as necessary. Given that CMS requires the IP to report to the QAA committee, the members of the QAA committee are well positioned to review IPC policies. The IP should present and review the IPC policies with the QAA at least annually, discussing those for which modifications may be indicated due to internal data, new evidence, or changes to local, state, or federal guidance. The IP is responsible for documenting policy changes and associated dates, which will support the annual review process.