Control infection with surveillance, intervention
JCAHO offers guidance for this problem area
Private duty providers wage constant infection control battles. But their attacks are sometimes misguided or overdone, missing Joint Commission on Accreditation on Healthcare Organizations (JCAHO) intent and failing to effectively improve overall outcomes, sources say. One of the most problematic JCAHO accreditation areas (see Private Duty Homecare, July 1997, p. 79), infection control can be conquered. Sources offer the following tips:
· Ensure that you follow applicable laws and regulations.
Adhering to federal, state, and even local requirements may seem obvious, but it is much easier said than done. One of the most challenging is the recently enacted Occupational Safety and Health Administration (OSHA) regulation promulgating two-step Protein Prepared Derivative (PPD) testing for any new employee at risk for exposure who cannot demonstrate a negative PPD within the past 12 months. "Its terribly problematic," says Kathy Morgan, RN, C, MPH, BSN, president of Homecare Education Specialists Inc., a Johnson City, TN-based home care consulting firm.
Don't get lost in the maze of regulations
Providers struggle with this requirement because it is "fairly new; it just came out last year, and they're not familiar with it. And then they get mixed signals because the county health department says 'no, its not required,'" she explains.
Staying on top of myriad regulations is unquestionably challenging. OSHA regulations are published in the Federal Register, and state and national home care associations generally do a good job of informing members of changes, Morgan notes. St. Francis Home Health in Tulsa, OK, relies heavily on National Association for Home Care regulatory updates, says Tecla Webber, RN, MBA, BSN, manager.
· Develop appropriate, reasonable policies.
Some providers adopt "very strict infection control policies [which are] not based on scientific principals and [do] not [reflect] what staff are doing," says Morgan. For example, some agencies' hand washing policies require a minimum 60 second washing including a nail scrub. This is not a common practice in home care, and most field staff members do not carry a scrub brush, she adds. A more reasonable policy would state that staff must thoroughly wash their hands before and after patient care, she notes.
Morgan believes such restrictive policies originate from what she calls "JCAHO myths." One example is that field staff must place a barrier underneath their bags. Many providers wrongly assume JCAHO requires this practice. Instead, an organization may have received a survey recommendation for violating their own policy that demanded bag barriers. Yet this is misinterpreted as a JCAHO standard. Webber concurs. "People have a mindset that JCAHO requires or wants the highest technique, [but that is not the case]."
Morgan advises periodic policy and procedure review and update to ensure that providers' requirements and field staff actions are in sync and in keeping with current home care practice.
· Don't select overly broad surveillance targets.
Providers sometimes go astray by tracking infections they cannot reasonably be expected to improve or by not tracking those they should. For example, many companies select an overly broad surveillance target like respiratory infections. To appropriately track such illnesses, field staff should report every instance of patients' receiving respiratory-related antibiotic therapy, a difficult task, especially with a largely elderly population.
Intervention is even more problematic. "Where did the patient get it? The physician's office? The grocery store? Its hard to say your staff did something to cause it, [and therefore difficult to reduce infection rates by some change in your operations]," Morgan says. Respiratory infections in patients on ventilators or those receiving tracheostomy care are more germane targets - with more identifiable vectors, she adds.
· Identify infectious agents so you can spot trends.
While many providers attempt to track the untrackable, others miss important trends by not identifying infectious agents. For example, Methicillin-resistant Staphylococcus aureus (MRSA), a highly contagious infection typically spread by home care workers through inadequate hand washing, is often not tracked, Morgan says. "A [company] may have one patient with it, and in three or four months, they may have several more and not realize that there's a trend," she adds.
To determine appropriate infection surveillance and intervention targets, private duty providers should rely on the following:
· federal, state, and local reporting requirements;
· regional epidemiology trends;
· characteristics of their own patient population.
Regional epidemiology trends are particularly important surveillance target guides. For example, in response to a large rodent population, many southwestern-based providers now track both Hantavirus and bubonic plague infections, Morgan says. St. Francis now tracks Vancomycin-resistant Enterococcus (VRE) after several cases accompanied patients home from the hospital, Webber says.
A company's patient population also dictates surveillance targets. For example, a predominantly elderly client base receiving much wound care, should prompt wound care infection surveillance and intervention. Providers can take many steps to reduce wound infection rates, such as focused assessment and wound care technique staff training and patient wound care and infection control education.
· Consider a roving supervisor to identify surveillance targets.
A roving supervisor who spends approximately 90% of her time in the field helps St. Francis identify surveillance targets. She pinpoints trends and recurring staff education needs, Webber says.
Despite their best efforts, providers sometimes find one survey misstep can waylay an otherwise well thought out and implemented infection control plan. Type One recommendations do result from observed infection control policy violations, Morgan acknowledges. However, the severity of the citation depends on the nature of the slip, she adds. "Observing one instance of a field staff member not following your hand washing policy would probably not warrant a Type One, but a nurse cross-contaminating two wounds, through either dressing or touch, probably would."
St. Francis' roving supervisor helps ward against such mistakes, Webber says. "Nurses get lax in technique and develop bad habits. They never know when [the roving supervisor] is going to accompany them" so it encourages people to stay alert and always use their best techniques. And the supervisor also helps staff identify lapses. For example, she may ask a staff member after a visit, 'Did you realize that you didn't wash your hands after you took your gloves off?'" Webber says.
· Incorporate infection control into your performance improvement program.
Private duty providers who most effectively meet infection control standards incorporate them in their performance improvement program, Morgan notes. In this way, "on a regular basis, some group is reviewing agency [infection control progress]," she adds. Infection control takes total staff involvement, she says.
Webber also advises, "Keep it simple. Pick one or two things [you know you should track and can improve]. Nurses are notorious for making it harder than we have to. And make sure you include field staff. Administrators tend to think we know all the answers and how it should be done, but nine times out of ten the field staff will say, 'That's not how it works in the real world.'"
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