Our elderly loved ones deserve to live out their final days with dignity and respect, not to be left alone to die in a broken system. Even before the COVID-19 pandemic, infectious diseases ran rampant in US nursing homes, between one and 3 million infections resulted in 380,000 deaths among nursing home residents each year. That’s over 1000 people per day, all because the nursing home industry has been struggling with infection prevention and control practices for decades. In Broken, Dr. Buffy Lloyd-Krejci exposes an industry in dire need of a massive policy overhaul. 

Travel with her to over 200 nursing homes across the country, as these deadly problems are brought into stark relief by the pandemic. Through interviews with patients, healthcare workers, advocate groups and regulatory agencies. Discover the critical flaws in a system that was set up to fail and one doctor’s bold vision for change. This is the Author Hour Podcast and I’m your host Frank Garza. Today I’m joined by Dr. Buffy Lloyd Krejci, author of a brand new book, Broken: How the Global Pandemic Uncovered the Nursing Home System in Need of Repair and the Heroic Staff Fighting for Change. 

Dr. Buffy. Welcome to the show.

Buffy Lloyd-Krejci: Thanks, Frank for having me. I’m excited to be here. 

Frank Garza: To start, I’d love to hear a little bit about your background and how that led to you writing this book.

Buffy Lloyd-Krejci: Sure. Well, I’m an Epidemiologist, Infection Preventionist. I’ve worked in healthcare, over 25 years in various roles, but more specifically, in infection control over the last about 10 years, really starting with the 2009 H1N1 pandemic. I worked in an Intensive Care Unit and really saw the devastating effects of viruses. It really fueled my hunger for wanting to learn more about viruses and really how they impact the community, specifically within a healthcare setting, such as nursing homes.

Frank Garza: When you wrote this book, who is the target audience you had in mind? Who did you write the book for?

Buffy Lloyd-Krejci: You know, the book really is a message to healthcare providers. It is a message honoring our health care providers specifically in our long-term care facilities. They are often vilified or really not given the understanding or credit that they deserve. Given my experience of working in over 200 nursing homes across the country during this pandemic, I wanted to be able to capture the truth of what was going on within the nursing homes and to honor those healthcare heroes that show up every single day and devote their care to this vulnerable population. 

I also wrote this book for the general public to really understand the truth of what is occurring in our long-term care facilities. As often all we hear is the bad news and it’s just not the full truth. Then finally I wrote it for politicians, for decision-makers to really help steer the conversation towards change and how we can promote a better health care system that supports our healthcare workers, as well as the residents for improved to safety.

Addressing the Problem and Protecting the Vulnerable

Frank Garza: You mentioned all the nursing homes that you have worked in and visited over the years and the first chapter of your book, “House on Fire”, talks about one of those nursing homes in Baltimore. Could you please describe what you experienced that day on that visit?

Buffy Lloyd-Krejci: Yeah. I was a recent business owner. I had started my company in an effort to really support nursing homes. I was asked as a favor just to come and visit this nursing home to evaluate — the person, my friend, was Crystal — and evaluate the care that her Aunt Nanny was receiving. I just came not as a consultant, but as a friend to listen. I remember coming in, and as I described in the book, the strong odor of urine smacking me in the face. I was just surprised that here it was in 2018 and we were still having this situation. I was able to participate in the family council meeting, as again, just an observer and my attention quickly came to life when the conversations was steered towards all of the infectious disease outbreaks that were occurring in the facility. 

I remember frantically taking notes. I was just stunned and shaking my head in disbelief, and also very grateful for those that were in the family council, such as Twila Bridges, who were advocating for change. When I left that meeting, I remember I said, “I’m here to help. I’ll do what I can.” I remember the outburst from a family member, she just was so angry, and she said, “You’re not going to help. They all say they’re going to help, but they don’t.” It really pierced my heart. I thought, “Well, they’ve not been heard.” I told her I had quit my job. I was dedicated to this cause and I was dedicated to helping and I would do everything that I could. 

I remember that, obviously, meant so much to me. Then I went down the hallway to visit Crystal’s aunt, and I had my Infection Preventionist hat on and I’m looking for access to being able to wash my hands, and there weren’t any hand sanitizer dispensers in the hallway. Then we went in the room, and you have to realize that people are sharing a room. So there’s — you know Nanny had a roommate. Then there were no hand sanitizers in the room. I’m thinking like, “How is anybody washing their hands?” A lot of these infectious diseases are spread by our hands. 

So if we don’t have adequate equipment, such as hand sanitizer, it’s impossible to be able to implement these basic infection control practices. That was a special day for me, because I met Nanny. I don’t know, she reminded me of myself a little bit, she was feisty, and just this go – just I don’t know, her attitude is spicy. She was in a lot of pain that day. We helped rub some lotion on her hip. I remember Crystal saying, “Buffy is here to help.” She says, “Good, we need it.” Then I write in the book, how she gave me a piece of her gum like it was such a special treat for her. So I knew that I made a new friend with her. 

When I left the nursing home, I was in such a state of anxiety and pain really, because I could leave. I got to leave, but these residents don’t. This is their home. This is where they stay and they’re vulnerable. They have multiple comorbidities, they need the care. So this is when I reached out to some CMS leaders that I knew of at the time, basically call to action to help with that facility.

Frank Garza: You mentioned in the book, how these problems with infectious diseases in nursing homes have existed long before COVID. Can you elaborate on that? How long have these been around? What research existed on them even before COVID?

Buffy Lloyd-Krejci: There have been — Yes, the infectious diseases, we have them in our health care system, whether it’s acute care, long-term care. What’s happened over the years within long-term Care is the acuity level or how sick somebody is, has gone higher. That means we’re caring for sicker and sicker residents in the nursing homes. Unfortunately, the infection control practices haven’t transferred with this higher acuity. The research is limited. I mentioned that in my book, but there are some definite pioneers in the research. Dr. Patricia Stone is one of them, Dr. Tamara Konetzka and Dr. Lona Moody. These are academic researchers that have been studying infections in long term care for over a decade. 

The research is limited, because we don’t actually collect infectious disease data in a manner that can really help us understand the true burden. What we know today and what we’ve known for years before the pandemic is that there’s an estimated one to 3 million infections within this healthcare setting that are occurring every year. From that we know that there’s an estimated 380,000 deaths from these serious infections. When we break that down, that’s over 1000 residents that are dying from these infections every day. Yes, I say this was before COVID. 

The issue was there, the problem was there. Quite frankly, we’ve just chosen to put the long-term care facilities last priority, as a last priority, for really solving this problem. There was a plan in place we were getting there. So in 2016, there was a new federal rule that required every nursing home in the country to have an ‘Infection Prevention and Control Program’. Then in 2017 to have an ‘Antibiotic Stewardship Program’. Then 2019, the end of 2019, to have at least a part-time infection preventionist on site. We were heading in that direction, we are definitely moving towards understanding this and implementing and combating this problem. Unfortunately, it just wasn’t fast enough as COVID hit early 2020.

Frank Garza: What are some of the most common infectious diseases that you see in nursing homes? 

Buffy Lloyd-Krejci: The most common is your urinary tract infection, which in this population can lead to Urosepsis. We know, you have to which can then lead to death. This is a common infection that when we’re talking about the elderly, we must identify it rapidly and treat it rapidly. There’s other infections, such as pneumonia, skin and soft tissue infections. We are seeing a rampant growth of multi-drug resistant organisms or MDROs. These are superbugs that are resistant to antibiotics. That’s why having an ‘Antibiotic Stewardship Program’ coupled with your ‘Infection Prevention and Control Program’ is essential because we must understand, and we must begin to decrease the overuse of these antibiotics, because we have the superbugs that are really beginning to become more rampant in our nursing homes, and in our health care settings, in our communities actually, that we have to address. We need to have our antibiotics work for us. 

All of this is very important in this long-term care setting, because you have the most vulnerable population, you have advanced age, you have immunocompromised, meaning their immune system doesn’t work as well as a healthy person. They’re more prone to infections. They’re in a congregate setting, so it’s easier to transmit the infections. So those are some of the common ones that we see, some of the common infections within the long-term care setting.

Taking Proactive Steps to Support and Work for the Nursing Home Community

Frank Garza: Talking about COVID, I know you had some firsthand experience being in these nursing homes during the pandemic; you write about your experience working with Doctors Without Borders in Detroit, Michigan. Could you share what you were doing with them and some more about your experience with that mission?

Buffy Lloyd-Krejci: This was a very unique opportunity for Doctors Without Borders or MSF, which is their French name. They had never had a US-based mission. Given that all the borders were pretty much closed, it was a unique opportunity to really open up a mission here in the United States. Doctors Without Borders is a global humanitarian organization, that really serves the under-resourced, the really the worst of the worst. So when an email came across my desk stating that they were looking for an IPC manager to join their team, I really jumped at the opportunity as it had actually been something I thought of as a young child working for Doctors Without Borders. I hadn’t really thought much of it over the years, but it was a great opportunity to really be of service and up until that point with my daughter and had a baby. 

I hadn’t really been out in the field as much during the pandemic, but this really gave me the opportunity to jump out in the middle of it. When we started in Detroit, it was a three-month mission, and then it moved to Houston, which was about a two-and-a-half-month mission. We basically were able to go into nursing homes that needed our help. Detroit, it was all done with all identified with epidemiology to understand what region was really hit the hardest, and Detroit was one of those regions. So we would go in and offer training and education. We would conduct an infection prevention and control assessment and really identify any gaps in their practices to keep the health care workers as well as the residents safe. 

What we will quickly found out and the team with Doctors Without Borders soon realized it was very difficult actually, to get into these facilities, given how punitive the nature is, in long term care. It was one more organization trying to get in the door. They didn’t know if we were really there to help or to issue a citation, or really what our purpose was. Once we did get in the door, and we were able to help them and support them, we were welcomed. We were really utilized in a manner to help train the staff for these best practices. What we also soon learned early on was that, we had these facilities that we call special flowers. My colleague, Karen had named them special flowers where they really needed more support, we just didn’t ethically or morally feel okay doing one site visit and then not coming back to help. I mean, they were really struggling. 

Basically, I would go into these special flowers and offer the one-on-one support, typically with ancillary staff, housekeeping, laundry, and then the CNAs as well. We would offer one-on-one support, to just give them basic training infection control training. It was very welcomed and it wasn’t uncommon that our housekeepers or people that we worked one-on-one would cry or break down and just, they were just so grateful for the help, they just weren’t used to that type of support. It was a really great opportunity. It was a very difficult time, because of where we were in the pandemic. We didn’t know it was June of 2020, so we thought maybe we had overcome it, we had that first peak already, but what we soon realized was that this is — infections and long term care, it’s a chronic situation and it wasn’t going to be fixed. Even with us there just a few months, it was going to take ongoing support for these facilities.

Frank Garza: In the latter part of your book, you start talking about how we can fix some of these problems. I’d love to hear, what do you think should be if you had to just pick two or three priorities that are just absolute must that we need to get in there and fix? What are some of those top priorities you think we need to work on right away?

Buffy Lloyd-Krejci: When I first started writing the book, I was writing the book from a standpoint of my experience as an infection preventionist. Then as I got deeper into writing the book, as I interviewed academic researchers, as I interviewed people in the nursing homes, I quickly realized this book just couldn’t be about infection prevention and control. Then I also quickly realized this problem was so much bigger than I could even capture in one book. I had to condense it to be what it is, and realizing that there are so many different factors that contribute the care that is provided, the care that we offer our staff and it’s kind of a whack a mole system. I think, I mentioned this in the book where you fix one thing, and then something else pops up and you fix something else, and then something else pops up. We’re very reactive in this health care setting where we’re just putting out fires all the time. 

My first solution is we’ve got to start being proactive. We’ve got to start implementing preventive practices, speaking from infection prevention and control, we need to implement that prevention piece, not just the control. We don’t want to just control and mitigate the infections once they’re in our building. We want to prevent them from ever coming into our building. We can, we absolutely can do this. But how are we going to do that when an industry has so many other challenges, such as staffing, and the regulatory and funding? I mean, the list goes on with all of these different issues. So my plea, actually, to even decision-makers is we’ve got to support our nursing homes better. We keep increasing our regulations and increasing the things they have to do, but what we don’t do is provide the support that is needed to go along with those requirements. It’s an industry that is continually getting more and more underground, you could say it’s just being smashed. 

I saw that in the field time and time again. It was confusing regulations, confusing requirements. That’s what people were stressed out with the regulatory people coming on site issuing citations. So we’ve got to begin working with our nursing homes instead of against them, which is how it often feels. Our health care workers, our staff deserve it. Ultimately, if you have happy staff, that’s going to contribute to happy, healthy residents. That’s what we all want.

Frank Garza: Writing a book is such a feat. Congratulations on getting this done. Is there anything else about you or the book that you want to make sure our listeners know, before we wrap up?

Buffy Lloyd-Krejci: What’s important for me is that this is just the beginning. Like I said, there is so much more information that could have been put into this book, but it was a high priority of mine to get it out to the public as quickly as possible, given the circumstances that we are all in. What’s important for me, if you have a loved one in a nursing home, to get involved to join the family council meetings to know how you can support your loved one in that facility. A lot of times, the family members may be left alone. So we need advocacy and so really having, if you have a loved one in a nursing home to get involved as much as possible. 

What’s so important for me to say is to the health care workers, the administrators, those that show up every day, just thank you. Thank you for what you have done. I’ve sat with you, we’ve cried together. Let’s keep this moving forward so that we can create change for the better. Our residents deserve it, our health care workers deserve it. I know that change is possible. 

Frank Garza: Dr. Buffy, this has been such a pleasure. Thank you so much for putting this book out into the world. The book is called Broken: How the Global Pandemic Uncovered a Nursing Home System in Need of Repair and the Heroic Staff Fighting for Change. Besides checking out the book, where can people find you?

Buffy Lloyd-Krejci: You can check out our website it IPCWell, and also other resources at doctorbuffy.com. We also have LinkedIn, Facebook, where we regularly post blogs and updated information. 

Frank Garza: Thank you, Dr. Buffy. 

Buffy Lloyd-Krejci: Thank you, Frank. Thanks for having me.