Healtcare Infection Prevention-Increasing use of devices fuels infections in home care
National infection control efforts lag
Increasing use of medical devices and more complex delivery of care contributed to a 16% infection rate in a study of Missouri home care patients, Centers for Disease Control and Preven tion investigators reported at the CDC's 4th Decennial International Conference on Nosoco mial and Healthcare-Associated Infections, held in Atlanta in March.
The CDC and the Missouri Alliance for Home Care — a nonprofit association that provides home care education, advocacy, and information — reported that 793 (16%) of 5,148 patients that were monitored in Missouri home care agencies during one month in 1999 had infections. In general, use of a urethral catheter was associated with a higher risk of urinary tract infection (UTI), while a central catheter was associated with a higher risk of bloodstream infection (BSI). Overall, 8% of the infections were considered home care-acquired, with the rest traced to community infections, other health care settings, or unknown origin. (See box, p. 2.) As data continue to emerge in home care settings, it appears infections linked to devices are going to occur much as they have in acute care settings, epide miologists reported at the conference.
"People who receive medical care in the home are at risk of acquiring the same infections as those in hospitals, like urinary tract infections, respiratory tract infections, surgical site infections, and bloodstream infections," says Lilia Manangan, RN, MPH, a medical epidemiologist in the CDC hospital infections program. "As is the case with infections acquired in hospitals, the use of medical devices like urinary and central venous catheters in the home appears to increase one's risk of acquiring an infection."
The data point to the need for health care providers to enhance efforts to prevent infections in the home, and the CDC is trying to expand its surveillance and prevention activities in the area. "We need to extend to home health care delivery the same standards we have applied to the hospital setting," says Julie Gerberding, MD, director of the CDC hospital infections program. "We have to monitor the frequency of these events and learn how to prevent them."
The number of patients treated in the home has expanded dramatically, with an estimated 8 million Americans receiving medical care in the home in 1996 (the latest year for which data are available), according to Michele Pearson, MD, a medical epidemiologist in the CDC hospital infections program. In that year, there were 8 million discharges to home care, a 150% increase from 1992. "Significantly, in 1996, 10% of home care patients had an invasive medical device, typically used in hospital settings, such as ventilators, urinary catheters, and vascular cathe ters." Pearson says. "I think it is safe to say that those numbers will continue to increase as health care delivery in the United States continues to change."
While the CDC findings add to the limited infection control data in home care, there is little standardization (i.e., use of common infection definitions) and scant resources dedicated to infection control, said Emily Rhinehart, RN, MPH, CIC, CPHQ, vice president of AIG Consultants Inc. in Atlanta.
"Infection control staffing in home care — that's an oxymoron," she told conference attendees. "There are very few except for the larger corporate entities who have a dedicated infection control professional. . . . Most of them do not, and they have nurses fulfilling [multiple] roles. They will be the infection control designee [as well as] occupational health, risk, safety, and they probably have to make sure the oil is changed in the cars in the fleet."
Acute care "answers" don't always apply to home care questions, and a wide variety of medical care and infection control approaches contribute to confusion in the home care arena. "Our goal in the next decade must be to drive some standardization of practice in all of these settings," she said. "Because in the principle of quality, variance is not good. Confusion is not good. We need to develop some data and develop some standardized infection control practices, which will decrease this variance. [That] will increase the quality of care and decrease the cost."
While praising the use of CDC benchmark infection definitions, Rhinehart said many home care systems may have to include a definition of "probable" infection based on signs and symptoms in the absence of culture results. "Home care nurses do not get reports from the microbiology lab. They don't get on their computer in their office every morning and pull up the positive cultures," she said. "They can't [walk] down to radiology and look at the chest X-rays. . . . You have to step back and say, 'what is the best that we can do?'"
The majority of patients receiving care in the home are older than 65, so the diseases and related infections are somewhat similar to those seen in long-term care, she said. Home care patients may have diabetes, congestive heart failure, coronary artery diseases, postoperative joint replacements, or cancer. "Aging brings on decreased ability to fight infection, so the management of chronic conditions is very important for host factors that would increase risk," she said.
Moreover, the procedures in home care are becoming increasingly complex, and that trend will continue, she added. "They will take a truck to your home and do laser surgery," she predicted. "Everything is, 'take the care to the people.' So there are many skilled and high-tech services being provided in the home."
Regarding use of devices, a common-sense approach in home care is to focus on reducing catheter days in general, Rhinehart added. "My view would be to get [home care nurses] to decrease catheter days, rather than necessarily setting a goal of actually decreasing UTIs," she said. On the other hand, surveillance and prevention efforts should be given a high priority for BSIs associated with home infusion therapy, she added. "If they are they are doing home infusion therapy, I believe that they are negligent if they are not doing surveillance for bloodstream infections," she emphasized.
BSIs increase with presence of risk factors
Indeed, a recent study of patients receiving home infusion therapy through central or midline catheters found that several factors contribute to BSI.2 Patient-associated risk factors were recent bone marrow transplantation and previous BSI. Patient care-related features were receipt of total parenteral nutrition, administration of intravenous therapy in an outpatient setting other than the home (such as a hospital clinic or physician's office), and use of a multilumen catheter. CDC guidelines for preventing catheter-related BSIs recommend using single-lumen catheters if possible. In the study, the BSI rate increased as the number of risk factors present increased. The infections ranged from 0.16 per 1,000 catheter-days in patients with no risk factors to 6.77 infections per 1,000 catheter-days in patients with three or more of the aforementioned risk factors, the authors reported.
In consultations with home care agencies, Rhinehart reminds that a basic difference in the home care environment compared to acute care is the absence of other patients who can serve as reservoirs for nosocomial infections. The downside of that is that home care is essentially an "uncontrolled environment," she said. "[For] those of you who have not heard the horror stories from home health nurses, it is not uncommon for them to go into a setting where there is no running water," Rhinehart said. "Or if there is running water and there is some plumbing, you are caring for someone in one room and you have to traverse many yards to get to a sink. If there is a sink, there may be soap and a towel, maybe not. So it's very challenging, in addition to anything from pets, little children, [to] lack of refrigeration."
Nursing staff levels in home care have not necessarily increased with the advent of high-tech care, resulting in situations where family members are the primary caregivers, she said. Conceding that one could argue that "the hospital is a very dangerous place," Rhinehart said, "they are at less risk with a trained loved one taking care of them than a nurse who is taking care of six other patients in an NICU. [But] certainly there is something to be said for the skill of someone who is trained and knows what they are doing."
References
1. Manangan LP, Schantz M, Pearson MI, et al. Prevalence of infections among patients in home care. Abstract PM1-27. Presented at the Centers for Disease Control and Prevention 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infection. Atlanta; March 5-9, 2000.
2. Tokars JI, Cookson ST, McArthur MA, et al. Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy. Ann Intern Med 1999; 131:340-347.
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