How clean are your infection control data?

Checks and balances keep it consistent

While it’s difficult to collect infection control data in a consistent manner, it’s even harder to make sure the data remain consistent.

These are the kinds of problems that may arise:

• A quality manager may have spent weeks training nurses in how to use a particular tool in collecting infection data, and then some nurses leave and new ones have to be trained again.

• The agency collects too much data, and the quality manager doesn’t have time to analyze it and make it meaningful.

• Nurses might occasionally turn their data in late, skewing quarterly infection reports.

A group of Missouri quality managers has developed a set of checks and balances that keep their data collection uniform. A committee called the Missouri Alliance for Home Care Infection Surveillance Project developed the system.

The project, started four years ago, involves more than 30 home care agencies and has an ultimate goal of benchmarking infection control data among these agencies.

So far, the group has agreed on common definitions for two different infections and has set up a consistent data collection and monitoring process.

Here are their suggestions for how quality managers can make sure their data collection process keeps their data clean and uniform:

1. Choose the method for recording data.

Nurses at Capital Region Home Health in Jefferson City, MO, keep track of how many patients have an indwelling bladder (foley) catheter or central line and whether any of these patients develop an infection, as defined in the project’s tool.

"It has to be active surveillance; the nurses keep track of that information and turn it in monthly," says Joan Kurtzeborn, RN, clinical supervisor for the hospital-affiliated agency that serves 12 counties in a small-city and rural area of mid-Missouri.

The project has designed a comprehensive, one-page active surveillance report for infection rates. It asks nurses to check any of 18 different signs and symptoms observed related to the presence of an infection. (See active surveillance report, inserted in this issue.)

The report also includes the following:

• 11 boxes to check that describe the site of the suspected or actual infection;

• a section that documents when the physician was notified and what medications and lab work were ordered;

• the results of any lab tests;

• whether the infection was communicable and reportable, and documentation that it was reported to the clinical supervisor within 24 hours.

The last step is putting this information in a database, and most of the agencies use a computer for this task. Then they turn their calculations over to the Missouri Alliance for Home Care in Jefferson City.

2. Make sure data are meaningful.

"They need to be comfortable with what they’re collecting, and it needs to be meaningful to them," says Eddie Hedrick, BS, MT(ASCP), CIS, manager of infection control and staff health services at the University of Missouri’s University Hospitals and Clinics in Columbia. Hedrick helped the Missouri committee with the project.

"The worst thing to do is to collect information that bores them to death because it doesn’t have any meaning to them," Hedrick says.

Quality managers also need to be sensitive to the possibility that some nurses will misunderstand the purpose of data collection and become concerned that it could be used to criticize their patient care. "Never should this kind of thing be done to point out where people did something wrong," Hedrick says.

"The idea is to look at the process that caused the problem, and it never should be personalized," he adds. "The person collecting it needs to be convinced that it’s not going to be used against him or her."

If these concerns aren’t addressed, then the data collection could become less meaningful, he explains, "because what’s the incentive to look for a mistake if the mistake is yours?"

The Missouri agencies have agreed to maintain confidentiality about their outcomes information. (See confidentiality statement, inserted in this issue.)

Quality managers also can ensure the data are more meaningful by tracking fewer types of infections. It doesn’t help the agency if mountains of infection data are collected, but the quality manager has no time to calculate infection rates and make sense of the information.

"The classic mistake in hospital epidemiology in the 1970s was that people in the field collected tons of information, to the point where the person collecting it had no time to do anything with the data," Hedrick says.

3. Keep an active surveillance.

In the hospital setting, Hedrick notes, surveillance would include watching for infection outbreaks and clusters. This is less important in home care because clusters of infections rarely are related, he states.

Hedrick says it’s more important for home care agencies to look for innovative ways to control infections.

For instance, it is fairly easy to disinfect and sterilize equipment in a hospital setting.

"But the patient at home can’t always afford to have a sterilized Foley catheter," Hedrick explains. "So the key is to take the alcohol and run through it not to disinfect it, but to dry it so nothing grows in it because bacteria doesn’t reproduce in a dry state."

Hedrick suggests another innovative measure is to place a hot iron on a handkerchief to kill bacteria, and then store the package catheter in the handkerchief.

The Visiting Nurse Association of Southeast Missouri in Kennett has actively monitored its infection data collection since joining the program in July 1996, says Pat Huttegger, RNC, BSN, quality improvement director.

Huttegger has learned through surveillance that the agency’s patients have had very few central line infections. When there is one, it raises a red flag.

"If I see an infection, I ask the nurse, Who’s providing the care of this catheter, and who is doing dressing changes?’ Then if the nurse says it’s the family, I ask, When did you last observe them?’" Huttegger says.

If the family is having difficulty performing the care properly, then the nurse will have to go back in the home and re-educate as needed, she says.

A problem did surface when the agency began monitoring the indwelling bladder catheter infections, she adds.

Some of the agency’s newer aides were providing perineal care incorrectly. They were failing to wipe from front to back, which meant they could possibly be contaminating the bladder catheter.

"So we did work with them to change that," Huttegger says.

The Missouri committee designed an active surveillance infection tracking report that provides room for 11 patients’ data. (See infection tracking report, inserted in this issue.)

It also includes boxes for information about the following:

• when a central line or indwelling bladder catheter was inserted;

• when it was taken out;

• number of patient days;

• interruption dates;

• whether there was an infection;

• date the infection was identified;

• date the infection was resolved.

4. Put in checks and balances.

The Missouri committee members say this step is crucial to maintaining high quality of data. Someone, whether a supervisor or the quality manager, has to check nurses’ infection reports to make sure they used the infection tool correctly.

When a nurse reports that a patient has one of the infections that’s being tracked at Capital Region Home Health, the quality manager pulls that patient’s medical record and verifies that the patient meets the criteria for infection, Kurtzeborn says.

Supervisors at the Visiting Nurse Association of Southeast Missouri look at nurses’ charts to double-check the infection data. "They verify that they did have lab work done, and they had antibiotics ordered, and those types of things," Huttegger says.

Then the information is sent to Huttegger, and if she has any questions about it she returns to the nurse or supervisor or looks directly at the patient’s chart.