Long-term care facilities in Utah: A description of human and information
technology resources applied to infection control practice
Makoto Jones MD*, Matthew H. Samore MD, Marjorie Carter MSPH, Michael A. Rubin MD, PhD
Department of Internal Medicine, University of Utah, Salt Lake City, UT
Background: Little is known about the implementation of infection control (IC) programs and infor-
mation technology (IT) infrastructure in long-term care facilities (LTCFs). We assessed the IC human
resources, IT infrastructure, and IC scope of practice at LTCFs in Utah.
Methods: All LTCFs throughout Utah (n ¼ 80) were invited to complete a written survey in 2005
regarding IC staffing, policies and practices, and IT infrastructure and capacity.
Results: Responses were received from 62 facilities (77.5%). Most infection preventionists (IPs) were
registered nurses (71%) with on-the-job training (81.7%). Most had other duties besides their IC work
(93.5%), which took up the majority of their time. Most facilities provided desktop computers (96.8%) and
all provided Internet access, but some of the infrastructure was not current. A minority (14.5%) used
sophisticated software packages to support their IC activities. Less than 20% of the facilities had inte-
grated radiology, diagnostic laboratory, or microbiology data with their facility computer system. The
Internet was used primarily as a reference tool (77.4%). Most IPs reported taking responsibility for routine
surveillance and monitoring tasks, but a substantial number did not perform all queried tasks. They may
have difficulty with feedback of specific unit and physician infection rates (43.2% and 67.7%, respectively).
Conclusions: Our findings underscore what has previously been reported about LTCFs’ IC human
resources and IP scope of practice. We also found that some IT infrastructure was outdated, and that
existing resources were underutilized for IC purposes.
Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and
When it comes to infection control (IC) practice, long-term care
facilities (LTCFs) face unique challenges because of their patient
population, the nature of the care they deliver, and their limited
resources.1-3Adaptation and success despite these limitations can
depend on LTCFs employing IC personnel with broad IC skill sets
and providing time-saving technologies. Information technology
(IT) has “stretched” resources by improving worker productivity in
many areas,4and may be able to do so in IC as well.5This report
describes the human resources, IT infrastructure, and range of IC
practice at LTCFs in Utah.
Since the late 1980s, separate IC guidelines have been written for
LTCFs.6Although LTCF patients are not subject to the same invasive
procedures and therapies as those in acute care hospitals, they
represent a large population of vulnerable individuals7,8with long
lengths of stay9and high rates of health careeassociated infection.2,6
Limited staffing, high staff turnover, funding difficulties, and slow
adoption of IT can impede efforts to address IC.10Infection Pre-
ventionists (IP) stationed at LTCFs are commissioned to prevent and
control these infections.8However, previous studies have demon-
strated that LTCFs are likely to be staffed by IPs with varying
credentials and training,11,12multiple responsibilities,2and difficulty
spending the recommended amount of time on their IC duties.2,3
In settings with limited time and resources, the appropriate
use of IT may increase productivity and improve adherence to
recommended practices in health care.13The use of IT to support
surveillance, analysis, and reporting has been suggested in LTCFs,
particularly in larger facilities,8but documented experience in this
setting is limited. In the acute care setting, IT has been applied
to surveillance in academic and community settings with some
success.14,15In smaller hospitals, Epi Info and WHONET software
(both free) have been used for IC purposes.16Electronic surveillance
by organism and infection type, along with tools for analysis, can
allow IPs to reallocate precious time as necessary.
Studies involving validated measures of IT sophistication have
been developed and applied in nursing homes,17but have not been
* Address correspondence to Makoto Jones, MD, Division of Epidemiology,
University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132.
E-mail address: Makoto.Jones@hsc.utah.edu (M. Jones).
Conflict of interest: None to report.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of
0196-6553/$00.00 - Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc.
American Journal of Infection Control 40 (2012) 446-50
applied to either acute care or long-term care IC. Moreover, these
studies directed surveys to IT personnel and might not reflect the
technologies available specifically to IP staff. To date, there has been
little description of the actual use of IT in LTCFs for IC purposes. One
report suggested that few LTCFs routinely perform electronic
surveillance of antimicrobial use and infection.18Even if LTCFs can
obtain software (some of which is free of charge), whether they
otherwise have sufficient IT infrastructure to support its use is not
Thisstudysought tocatalog the human andITresourcesat LTCFs
that can be applied to IC, as well as the breadth and scope of IP
practice in LTCFs. As the latter grows, we would expect that
resources necessary to meet IC needs will expand as well. A
detailed description is the first step in designing studies to explore
the highest and best uses of IT and the necessary elements of IT
infrastructure to produce both efficient and high-quality IC.
We targeted the individuals assigned primary responsibility for
IC in the state of Utah who practice at LTCFs, identified by their
affiliation to an LTCF. We generated a list of all such facilities in Utah
by searching for all LTCFs in the Center for Medicare and Medicaid
Services (CMS) database that matched the CMS definition of
a nursing facility, but excluding facilities identified as transitional
care units. LTCFs were categorized as rural if they met the criteria of
the Office of Management and Budget19for a rural area and as
urban otherwise. Surveys were mostly completed by phone, but if
the survey could not be completed in this way, then paper surveys
with reply-paid, preaddressed envelopes were sent and received by
U.S. mail to and from LTCFs during 2005. Participating IPs were
compensated for their time with a gift card. All surveys entered into
the study were completed by December 2005.
The survey was adapted from a previous survey designed to
assess IC programs in small rural hospitals.20That survey itself was
modeled after the Study on the Efficacy of Nosocomial Infection
Control (SENIC) study,21the Intensive Care Antimicrobial Resis-
tance Epidemiology (ICARE) project,22and membership surveys by
the Association for Professionals in Infection Control and Epide-
miology (APIC).11Modifications to the previous survey had been
made by representatives from the Centers for Disease Control and
Prevention (CDC), CMS, Qualis Health, and HealthInsight and were
pilot-tested for content validity at that time, before publication.20
The current survey consisted of 33 questions: 5 questions
covering the facility and its IC human resources, 17 questions
covering the scope of IC practice, and 16 questions assessing the
facility’s existing IT infrastructure.
An IP’s skills are the human resources of IC. Education and
training are associated with the capacity to do skilled work. In
economic models, these qualities have been shown to be important
contributors to productivity. Our questions assessed credentials,
roles, and work experience. Because work performed is the product
of productivity and time, we also measured the time allocated to IC
per bed in the facility surveyed.
Assessing the quality of IT infrastructure is difficult given the
rapid changes in hardware and software technologies, so quality
may depend on the time period in which it was assessed. More
portable concepts of IT sophistication have been proposed,17,23but
have been validated for use only on IT professionals. Instead, we
classified our questions on whether they assessed basic, support,
applications, and integration infrastructure, a concept borrowed
from the work cited earlier. All 4 of these factors are necessary to
sustain optimal technological support of IC tasks. Basic infrastruc-
tureencompasses the numberand currencyof hardware devices, as
well as the operating systems that make them usable. We consid-
ered an LTCF up to date if it provided desktop computers
throughout the facility and to the IP and used technology that was
no more than 4 years behind the newest available in 2005. Thus,
operating systems released before 2001 and Internet access tech-
nologies older than broadband were considered out of date. The
4-year time frame was chosen after reviewing a variety of position
statements from states and businesses.24-27The reasoning behind
this time limit is that data security and IT support become difficult
with heterogeneous and outdated systems.25-27
Applications infrastructure pertains to processes supported
by IT applications, including computer-generated line listings,
antibiograms, and data analysis. We assessed IT-supported IC
functions and the number and types of software used for IC in
facilities. Support infrastructure refers to organizational support
from an IT department. Integration infrastructure refers to the
integration of different systems, such as microbiology, diag-
nostic tests, and radiology results, into the facility’s electronic
medical record system. We limited our questions to those that
were more solidly within an IP’s scope of understanding and
A total of 187 coded elements were extracted for analysis from
the survey. Most survey questions were either binary or open-
ended. The questions were framed to elicit the IP’s understanding
or knowledge, not necessarily the underlying truth. The survey is
available from the authors on request. Survey data were manually
double-entered into an ACCESS 2003 (Microsoft, Redmond, WA)
relational database and cross-checked for reliability.
In our descriptive analyses, data from incomplete answers were
not included in the numerator or the denominator. Some responses
were given in the form of ranges; for the purpose of analysis, the
average of the range was taken. When a value was modified by an
inequality operation or “þ”, then the value was entered without
modification. Responses such as “don’t know” were considered
Comparisons of ordinal variables and medians were done using
the Wilcoxon rank-sum test. The Student t test was used to
compare continuous variables, with appropriate adjustment made
for whether or not the assumption of equal variance was met. All
analyses were performed using Stata 10.0 (StataCorp, College
This study was approvedbythe Universityof Utah’s Institutional
Of the 93 identified LTCFs, 13 were excluded because they were
technically transitional care units, leaving 80 candidate LTCFs for
the survey. All were sent a request for participation, and 62 replied,
for a response rate of 77.5%. The responding facilities reported an
average of 87.9 beds and an average of 71 residents (Table 1). The
majority of facilities were from urban settings (61.3% vs 39.7%
rural); however, rural facilities had a higher response rate (96% vs
69.1% urban; P ¼ .008).
M. Jones et al. / American Journal of Infection Control 40 (2012) 446-50
IC human resources
Most IPs were registered nurses (RNs; 71%) with 2 or more years
of unstructured, on-the-job training (87.1%). A minority listed
either licensed practical nurse training (24.2%) or an advanced
nursing degree (3.2%). Those with primarily administrative
credentials made up the remaining 6.5% of respondents. Nearly all
IPs (93.5%) assumed additional roles, most frequently as a director
or assistant director of nursing or another administrative role
(Table 2). IPs also indicated having a number of educational and
quality assurance roles. Relatively few (12.1%) indicated that they
performed routine direct patient care duties. The most frequent
formal training reported was from Rocky Mountain Infection
Control (35.5%). Corporate and in-house training accounted for
another 17.7% of training. Those with national organization-level
certifications were a small minority, with 14.5%, 6.5%, and 6.5%
holding certification from the APIC, Society for Healthcare Epide-
miology of America (SHEA)/CDC, and the Certification Board of
Infection Control and Epidemiology, respectively.
The average IP worked a 45-hour week and spent 8 hours on IC
tasks (Table 2). Assuming that one full-time equivalent (FTE) is 40
work hours per week, the median number of FTEs per 300 beds was
0.52 (interquartile range [IQR], 0.34-1.1).
Basic and support infrastructure
Desktop computers were available in all but 3.2% of the LTCFs,
and 82% of IPs had theirowncomputers at work. The most common
locations of computers were administration offices (98.4%), and the
least common were physicians’ offices (25.8%). The most common
operating system on facility computers was Windows XP. We
considered this an up-to-date operating system at the time of the
survey. However, 25.8% LTCFs had an operating system that was at
least 4 years out of date, and one LTCF still reported using Microsoft
Disk Operating System (MS-DOS). All facilities reported having
access to the Internet, but 9 reported using a dial-up modem, and 8
of these reported dial-up as their sole Internet access. Of the IPs
who reported having their own computers at work, 94% also had
Internet access. In most cases, the modality of Internet access
available for the IP’s computer was the same as that of the facility.
Administration staff used desktop computers at 96.8% of LTCFs;
nursing staff,at54.8%;unitclerks,at50%; andIPs,at43.5% (Table3).
Other departments and services that reported using computers
included medical records, central supply, reception, social services,
and dietary services.
IT personnel were available to assist with computer setup,
training, use, and support in 85% of the LTCFs. New staff were
trained in computer use as part of their orientation in 54.1%.
The most common reported uses for LTCF desktop computers
were Internet access (95.2%), order entry (72.6%), and IC
surveillance and reporting (69.4%) (Table 3). Other reported uses
included patient charting, checking test results, and preparing
financial and administrative reports, especially for the CMS.
When available, the Internet was used by employees in capac-
ities ranging from administration to clinical care (Table 3). Among
these users, the Internet was used for communication in 82.8% of
facilities. The next most common reported uses were for obtaining
information on medications and treatments (81.3%) and IC practice
(71.9%). When we asked an open-ended question about how the
Internet helps (or could help) with their IC work, the majority of
respondents (77.4%) indicated that the ability to look up informa-
tion was useful. Only 7.5% specifically volunteered that communi-
cation helped with their IC responsibilities.
Most IPs (90.3%) reported that computers make (or would
make) them more productive. They cited the ability to use
computers for reference and research (48.2%), reporting (41.1%),
data storage and retrieval (37.5%), and analysis (23.2%) as important
supported functions. A minority of individuals (9.7%) did not feel
that computers are helpful and believed that their existing manual
processes are sufficient for IC.
Specific IC functionality was assessed by the use of software
programs that support IC tasks. Microsoft Excel was the most
common software used (44.3%), followed by custom facility-
specific software (38.3%), and Microsoft Access (27.9%). Few LTCFs
used any of the common epidemiology packages AICE,28IDEAS,29
or Epi Info (which is freely distributed by the CDC30). The
maximum number of software packages used was 4, reported by 1
facility. Sixteen percent used 3 packages, 25.8% used 2 packages,
35.5% used 1 package, and 21.0% used no software.
Generating microbiology data for review and preparation of
antibiograms lends itself to automation. Although 55 IPs reported
reviewing all positive microbiology data, only 12.7% of these data
were generated electronically. Twenty-three facilities reported
generating antibiograms; of these, 43.5% were generated by
computer. However, based on the responses, many of these anti-
biograms appeared to have been generated by outside laboratories.
IP workload and characteristics
Credentials, n (%)
Licensed Practical Nurse
Training, n (%)
Attended official APIC training courses
Completed SHEA/CDC training course
Completed certification process (eg, through CBIC)
Participation in Rocky Mountain Infection Control
Two years (or more) of on-the-job training/practice
No specific IC training
Director of Nursing or Assistant Director of Nursing
Average total number of hours worked each week,
Average total number of hours spent on IC tasks per
week, median (IQR)
CBIC, Certification Board of Infection Control and Epidemiology.
Facility characteristics from respondents
Number of beds*
Number of residents
*Beds include operational and licensed beds.
M. Jones et al. / American Journal of Infection Control 40 (2012) 446-50
The level of integration was assessed by how well different
systems (eg, radiology, diagnostic, laboratory, microbiology) were
integrated into facility computer systems. Twenty-one percent of
the respondents reported that radiology reports were available on
theirfacility’s computersystem.The median time to receivingthese
radiology results was 11.5 hours on the computer and 1 day (on
a day scale) when reports were not available on computer. In 7
facilities, films were available online. Some 76% of the facilities
without radiology integration received reports by fax. Results were
reported to the physician by fax or, when necessary, by phone, in
67.3% and 59.2% of facilities, respectively. The findings for both
diagnostic laboratory and microbiology systems were comparable,
although differences in the time to receiving results were less
pronounced (data not shown).
Scope of practice
Half of the IPs reported being responsible for all of the activities
listed in the survey. The 2 activities that IPs reported participating
in the least were reporting diseases to public health authorities
(16.1%) and educating and training health care workers and
providers (16.1%). Sixty-eight percent of IPs reported monitoring
all 7 surveillance elements in our questionnaire. The 2 elements
omitted most often were primary bloodstream infection rate
(19.4%) and employee bloodborne exposures (12.9%).
We assessed whether IPs generated 5 types of reports: positive
cultures, drug-resistant organism prevalent admissions, trends in
antimicrobial resistance, trends in target organisms, and trends in
nosocomial infection. Eighty-seven percent of facilities reported
trending nosocomial infections over a specific period. Only 50%
generated a report of admitted residents with history of previous
colonization or infection with a drug-resistant organism, and only
27.4% generated all of the reports.
Three facilities reported not providing any of the types of
feedback about which we inquired. Otherwise, 90.2% reported to an
IC committee or quality improvement committee, 67.7% provided
feedback to specific units, and 53.2% provided feedback to indi-
Rural versus urban comparison
Urban LTCFs had a median of 84.5 beds (IQR, 61-120), and rural
facilities had a median of 67 beds (IQR 57.5-102). The majorityof IPs
were RNs in both urban (71.8%) and rural (66.7%) settings. More
than 90% of IPs in both settings had additional roles. The median
number of hours spent on IC was 5 in urban settings and 7.5 in rural
settings. None of these comparisons were statistically significant.
We have presented survey data from 77.5% of the LTCFs in Utah,
a state with approximately 2.7 million inhabitants.31We found that
most IPs were RNs who had received 2 or more years of unstruc-
tured, on-the-job IC training. Official training or certification from
national organizations was relatively rare. Most IPs spent the
majority of their time performing duties related to their non-IP
roles in the LTCFs. The median FTE devoted to IC was 0.5 per 300
beds, which is at odds with the guideline suggestion of 1 FTE for
every 250-300 beds in LTCFs.8
Although most facilities had desktop computers and Internet
access, some of these systems were out of date. IT support was not
universal in the LTCFs. This could lead to problems with security
and application failures. Most IPs did not use sophisticated IC
software. Easily automatable tasks, such as generating line lists for
positive microbiology tests, were not usually supported with IT.
Other automatable tasks, such as antibiogram generation, were
usually generated by outside laboratories. The integration of radi-
ology, laboratory, and microbiology data with facility computer
systems was lacking in most facilities. The Internet was used
primarily as an information resource tool.
Most facilities reported that IPs performed the individual IC and
surveillance activities listedonourquestionnaire; however,a substan-
tial proportiondidnot performall of them.Inparticular,IPs frequently
did not feed back reports to wards and physicians.
Numerous previous studies have compared IP attributes and
practices.1-3,20,32-38One notable study performed in Utah in 198033
also found low levels of specific IC training, but no routine
surveillance or patient care monitoring practices were recorded at
the time. The low levels of SHEA-recommended training and
certification are consistent with those reported previously in rural
acute care hospitals,20in LTCFs,2,3and in the intermountain region
in general.12Our finding that IPs had additional, non-IC duties has
been reported by others as well.2,20,33Overall, the IP characteristics
and scope of practice revealed in the present study are consistent
with the literature.
The main limitations of the present study are related to gener-
alizability and time frame. Our response rate was roughly equiva-
lent to or better than that reported in recent comparable
studies,2,3,20,35,36but our survey in Utah might not apply to all areas
of the United States. Nonetheless, we do believe that many of our
findings will be relevant to the American west and southwest and
to rural areas in general. The significantly different response rate
between urban and rural facilities makes it difficult to draw any
conclusions about differences between the 2 settings secondary to
selection bias. We recognize that the survey was performed in 2005
and that IT advances rapidly, but because our measures of IT
Use of desktop computers and the Internet
Who uses the desktop computers?
What functions are the desktop computers used for?
Checking laboratory test results
Accessing the Internet
Who uses the Internet in your facility?
Director of Nursing
What is the Internet used for in your facility?
Accessing patient data
Obtaining information on medications, treatments, etc.
Obtaining information related to IC practice
Communication (e-mail, newsletters)
Obtaining career information
M. Jones et al. / American Journal of Infection Control 40 (2012) 446-50
technological sophistication were relative to circumstances in
2005, our assessment of the adequacy of IT resources should be
more robust to time.
In conclusion, we find that a focus on improving IP training and
time commitments to IC may improve the amount of IP work that
can be performed. When most IP training is still on-the-job training,
Internet access to IC resources is paramount. Improving Internet
access and attitude toward use will facilitate keeping IPs current in
their knowledge and improve communication within LTCFs. The
latter is important, because service and provider feedback appeared
to belacking. Also, asof this survey, there isevidence suggesting that
IC functions are not supported by hardware and software to the
greatest extent possible. This is the case even as free software
packagesareavailable (EpiInfosince 1985andWHONETsince1989).
LTCFs appeared to struggle with integrating independent electronic
described as “low-technology” environments,8they are unlikely to
continue to be so, especially as some anticipate gains in quality of
care delivered in this setting through the application of health IT.10
LTCFs are not currently eligible for health IT incentive programs in
the United States,but there are plans to encourage meaningful use in
these facilities.39Focusing on adherence to APIC/SHEA guidelines for
IP training as well as addressing deficiencies in IT basic applications,
support, and integration infrastructure may improve IC in LTCFs.
We would like to acknowledge Kurt B. Stevenson, MD, MPH, for
providing his survey of rural hospitals for adaptation in this study,
as well as a critical review of the manuscript. This study was sup-
ported by Agency for Healthcare Research and Quality Grant
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