The challenge of infection control
Definitions and methods under development
Home care infection control surveillance is a tricky business. (See June 1998 Private Duty Homecare, p. 86.) Providers tend to select overly broad surveillance targets or community-acquired infections they cannot improve through their practice, or fail to track those they should.
Lack of standard definitions, methods, and inadequate training of those charged with infection control contribute to the problem, according to Emily Rhinehart, RN, MPH, CIC, CPHQ, vice president of the healthcare division of AIG Healthcare Management Services in Atlanta. Rhinehart and Mary Friedman, RN, MA, wrote Infection Control in Home Care, published by Aspen Publishers in Gaithersburg, MD. The book is due out in March 1999.
"Home care infection control is very challenged. It’s about 25 years behind hospitals, and needs standard definitions and methods," Rhinehart says.
The National Nosocomial Infections Surveillance System (NNIS), a project of the Hospital Infections Program of the Centers for Disease Control and Prevention (CDC) in Atlanta, measures nosocomial infection rates among participating hospitals.
"From the NNIS database, you can find out the average number of hospitalized people with cath-related urinary tract infections. In home care, there is no comparable data," Rhinehart explains.
The NNIS system provides common definitions and tracking methodology even for hospitals not participating in the program. While home care providers can rely on the NNIS infection surveillance principals, the hospital-focused definitions and methods don’t fit, according to Rhinehart. "In home care, a diagnosis of infection is made by a nurse calling in an assessment, usually without cultures. We treat things empirically."
With no industry wide benchmark data, providers are hard-pressed to compare their infection control practices with others — a key element in performance improvement and outcomes studies. Help is on the way, however.
In 1993, the Infection Control Committee of the Missouri Alliance for Home Care (MAHC) began developing definitions and criteria for home care infection surveillance. After collecting pilot data and refining definitions, the Committee started gathering data on infections associated with central venous catheters and bladder catheters from participating MAHC members in 1996. The project expanded to non-Missouri providers in 1997 in response to heightened interest from out-of-state companies seeking comparative home care infection data.
Initiatives to develop methods, definitions
A total of 53 providers — 40 based in Missouri, and 13 out of state — now participate, according to Anne Brinker, project manager at MAHC. To join the project, Missouri-based providers must also be MAHC members. Out-of state providers pay a $300 participation fee initially, then $200 a year subsequently.
The MAHC data allows home care providers to compare their central venous catheter and bladder catheter infection rates with those of other participating providers. While it is an important starting point, the data is not without limitations. It is not risk-adjusted or stratified, for example, so "we caution participants not to go ballistic if their numbers are out of line," says Brinker.
MAHC and CDC recently initiated several collaborations to enhance the robustness of MAHC project data and create further home care infection surveillance resources. First, in mid-December, they expect to jointly issue an Infection Surveillance Resource and Infrastructure Survey to all Missouri-based home care providers; not only those participating in the MAHC project.
The survey is designed to determine the level of infection surveillance preparedness in home care. It asks questions about the background and other responsibilities of those responsible for infection control in each organization, as well as the resources for and infrastructure of infection control in each company, according to Brinker.
CDC also plans a retrospective review of selected patient charts from MAHC project participants to further test MAHC definitions and identify risk factors. After it completes the retrospective study, CDC has agreed to perform a point prevalence study, which will identify the number and types of home care infections in Missouri in a specified period of time.
In addition to the MAHC-CDC activities, the Home Care Membership Section of the Associa-tion for Professionals in Infection Control and Epidemiology (APIC) in Washington, DC, is developing a full set of long term care and nosocomial definitions as they occur in home care, according to Freda Embry, RN, BSN, CIC, home care membership section leader, and director of Risk Management for Lifeline Home Health Care in Somerset, KY. The group plans to complete its work by spring 1999.
While current efforts will ultimately lead to much-needed home care-specific surveillance data, it offers little support for the here and now of providers’ infection control responsibilities. Rhinehart recommends several steps to make the most of existing infection surveillance and control efforts.
• Educate those with infection surveillance responsibilities.
"The people developing surveillance don’t have the background to do it. Just because you’re a nurse and know the patient care aspects of infection control, doesn’t mean you know infection control," she explains.
• Evaluate your patient population and select targets.
With professional staff input, assess your patient population and scope of services. "Ask, Who are we taking care of; what are our services; and where’s the greatest risk of acquired infection?’" Rhinehart recommends.
When selecting surveillance targets based upon your patient population, consider the morbidity, mortality, and cost of treating infections. Complications on each side of these considerations are appropriate targets. For example, urinary tract infections (UTI) in patients with catheters "are the most frequent infections in acute care [settings] — probably in home care — but there’s no validating data," according to Rhinehart.
With a high prevalence but low associated mortality and treatment costs, UTI may be an acceptable target, depending on your patient population, she explains. On the other hand, respiratory infections in ventilator patients are infrequent, but have an increased mortality risk and can be very expensive to cure, especially if they require hospitalization.
You should also focus on infections that are preventable by something that you can control. For example, the unqualified UTI is overly broad because it includes UTIs in elderly ladies without catheters, and "that’s something that just happens in that population with aging and anatomy," Rhinehart explains.
Many providers also err by selecting com-munity-acquired infections. "It’s the biggest mistake people make," Rhinehart notes.
• Identify methods, develop definitions and collect data.
With no other home care definitions available, Rhinehart suggests using NNIS definitions as a reference for those examining targets not included in the MAHC project.
Definitions should include both clinical signs, symptoms, and at least one objective biological measure. Clinical signs and symptoms should identify a group of potentially infected patients that the biological measure reduces. For instance, patients with changes in their urine such as cloudiness and odor may have a UTI or some other condition. A white blood cell count obtained by dipstick or urinalysis would identify actual infections, Rhinehart explains.
Targets and definitions should be evaluated against the organization’s actual patients.
Rhinehart recommends having the two or three individuals most involved in infection surveillance screen at least 30 patients using your definitions. This will pinpoint any problems in applying or understanding definitions.
With refined definitions, providers should next conduct a pilot project for at least three months. "If you don’t come up with anything, then someone’s not reporting signs and symptoms," Rhinehart warns.
You need almost a year’s worth of data to calculate true incidence rates; the first few months’ data are not as reliable because of staff inexperience in identifying and reporting potentially infected patients using new definitions, she adds.
Providers will eventually be able to compare their infection control practices against others; even with no outside comparison, "you can at least compare yourself overtime and see whether you’re doing better or worse than before," Rhinehart says.
Providers may also consider collaborating with other home health agencies to agree upon definitions, collection methods and compare outcomes among themselves. Embry’s employer, Lifeline Home Health Care, and three other companies have done so. The results of their 1995 experience have been published, and may serve as a helpful resource to those considering a joint project or reviewing their own infection surveillance program, Embry notes.1
Reference
1. Rosenheimer, et. al. Infection surveillance in home care: Device-related incidence rates. Am J Infect Control 1998; 26(3):359-363.
Sources
• Anne Brinker, project manager, Missouri Alliance for Home Care, 2420 Hyde Park Road, Suite A, Jefferson City, MO 65109. Telephone: (573) 634-7772.
• Freda Embry, RN, BSN, CIC, Home Care Membership section leader, Association for Professionals in Infection Control and Epidemiology, 1275 K St. N.W., Washington, DC 20005. Telephone: (800) 933-0702.
• Emily Rhinehart, RN, MPH, CIC, CPHQ, vice president, Healthcare Division, AIG Healthcare Management Services, 5 Concourse Pkwy., Atlanta, GA 30328. Telephone: (770) 671-2195.
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