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Transcript
Infection Control in
Home Healthcare
An Exploratory Study of Issues
for Patients and Providers
Irena Kenneley, PhD, APRN-BC, CIC
The number of home healthcare clinicians who
have acquired an infection as the direct result
of patient care is not known. How clinicians
practice infection prevention and control in
home healthcare is also unknown. To describe
infection prevention and control policies and
practices in the home healthcare setting, an
exploratory study in the form of a 22-question
survey was conducted. Findings confirm the
presence of occupationally acquired infections
among home healthcare clinicians and that
infection prevention and control practices vary
widely across agencies.
vol.
vol. 30
30 •• no.
no. 44 •• April
April 2012
2012
Home
Home Healthcare
Healthcare Nurse
Nurse
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
235
235
Background
With the ever-increasing shift of patients out of
the acute care setting and into other settings, infection prevention and control programs must
also shift focus. Although home healthcare has
expanded in the United States, infection surveillance, prevention, and control efforts specific to
healthcare delivered in the home have not kept
up with this growing demand (Jarvis, 2001). Current clinical practice guidelines set for acute and
long-term care institutions have been used to
“bridge the gap” to the home healthcare setting
(Manangan et al., 2002). The home healthcare
setting differs from institutional healthcare settings significantly, however, and questions persist about the suitability of adapting institutional
guidelines to home healthcare (Jarvis, 2001). For
example, in the home healthcare setting, patients
with open wounds or central venous catheters
may undertake activities of daily living, such as
bathing, exercising, gardening, and playing with
pets.
Home healthcare agencies (HHAs) develop
policies and procedures for infection prevention
and control by adapting existing guidelines from
the Association for Professionals in Infection
Control (APIC, 2005), the Centers for Disease
Control and Prevention (CDC) Program Healthcare Infection Control Practices Advisory Committee (CDC HICPAC, Siegel et al., 2007), or the
U.S. Department of Health and Human Services
(DHHS, 2010), among others. Agencies may also
follow recommendations for home healthcare
developed by infection control (IC) and clinical
professionals (e.g., Carrico & Niner, 2002; Flores,
2007; Friedman, 1996; Friedman & Rhinehart,
1999; Hanchett, 1998; Rhinehart, 2001; HICPAC,
2006; Rhinehart & McGoldrick, 2006; Rice, 2001).
Adaptation of institutional guidelines to the home
healthcare setting can be challenging, however,
so substantial variation in practice exists (DHHS,
2002; Shaughnessy & Hittle, 2002). Hospitals and
long-term care institutions are controlled environments, compared to the uncontrolled patient
home environment where home healthcare is
delivered. However, the risk of transmission of
infection associated with multiple patients receiving care from multiple providers in one area
of an institutional setting is not present in the
home healthcare setting.
There are growing concerns regarding the spread
of multiple-drug-resistant organisms (MDROs),
236
Home Healthcare Nurse
such as methicillin-resistant Staphylococcus aureus
(MRSA), which is not only healthcare-acquired,
but has become community-acquired as well
(Barrett & Moran, 2004). In addition, the H1N1
swine flu pandemic and the presence of H5N1 influenza in Southeast Asia have reawakened fears
of a worldwide influenza pandemic of the sort
that occurred in 1918. It is estimated that up to 1.9
million people in the United States could die if
such an outbreak occurs (Agency for Healthcare
Research and Quality [AHRQ], 2008; CDC, 2010). It
is projected that home healthcare will be the
focus of patient care activities should such an
event occur (AHRQ, 2008). This issue is highly
relevant for home healthcare; therefore, an evidence base for prevention and control of MDRO is
needed. There is little research literature in this
area of home healthcare. As a result of this study,
the researchers seek to provide information from
the home healthcare setting about isolation precaution practices for patients with infections
caused by MDROs, and the presence of occupationally acquired MDRO infections among home
healthcare clinicians.
Significance
Infection and Infection Control
Microscopic organisms are everywhere; some
may cause disease, some do not. Under certain
circumstances, some cause illness. The vast majority of microorganisms are directly or indirectly
beneficial, such as the protective value of our
own normal flora. Bacterial microorganisms
cause disease by adherence to a host (person),
by colonization or invasion of host tissues, and
sometimes by invasion of cells. Infection is described in terms of the epidemiological triangle,
or the interactions of agent (microorganism),
host, and environment. Healthcare-associated
infections can be acquired by all modes of transmission that occur in the community. Direct personto-person transmission, indirect transmission
through equipment and supplies, and transmission through air are most commonly associated
with infections acquired in healthcare delivery
settings. Infected humans or contaminated medical equipment can become reservoirs or carriers
that can transmit diseases to others. Healthcareassociated infections can be exogenous (i.e.,
from the environment outside the body) or endogenous (i.e., opportunists found in the patient’s
own flora). Statistically, about 50% of infections
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are caused by only four pathogens
(Escherichia coli, Streptococcus,
Group D, S. aureus, Pseudomonas
aeruginosa); many strains of
which are antibiotic resistant
(Talaro & Chess, 2012).
Key elements of IC include the
circumstances under which isolation precautions are instituted
for patients, when and how patient infection or colonization
status is communicated to frontline clinicians, and when and
what type of dedicated equipment is used for patients with
confirmed infections. Policies
and practices vary between
HHAs for all of these elements
(Shaughnessy & Hittle, 2002).
The goal of infection prevention
and control program is to prevent transmission of infection.
Although safety and health of
the patient is paramount, protection of healthcare workers from
occupationally acquired infection is also of great importance.
Occupationally Acquired
Infections in Home
Healthcare
Table 1. Possible Healthcare-Associated Infections
(HAI): Some Infectious Diseases That May Be
Transmitted in Healthcare Settings
Bacterial/Parasitic Organisms
Viral Organisms
Acinetobacter baumannii
Chickenpox (Varicella)
Burkholderia cepacia
Creutzfeldt-Jakob Disease (CJD Prion)
Clostridium difficile
Ebola (Viral Hemorrhagic Fever)
Clostridium sordellii
Hepatitis A
CA-MRSA Community-acquired methicillin
resistant Staphylococcus aureus
Hepatitis B
Diphtheria Corynebacteria diptheriticum
Hepatitis C
MRSA methicillin resistant Staphylococcus
aureus
HIV/AIDS
Multiple drug resistant Gram Negative
Rods (KPC organisms) Klebsiella
pneumoniae
Influenza
Salmonellosis
Mumps
Scabies (Sarcoptes scabiei)
Norovirus
Streptococcus pneumoniae (drug resistant)
Parvovirus
Tuberculosis
Poliovirus
VISA: vancomycin Intermediate
Staphylococcus aureus
Rubella
VRE
SARS
Source: Division of Healthcare Quality Promotion (DHQP), National Center for Preparedness, Detection,
The literature concerning home and Control of Infectious Diseases (2006).
healthcare clinician/employee
direct contact (herpes simplex virus, Sarcoptes
health, occupationally acquired infections, and
scabiei [scabies]). Most outbreak-associated attack
protection of home healthcare clinicians from
rates range from 15% to 40%.
infectious disease is sparse. In a seminal article
Occupational transmission is usually associpublished in 1985, Haley et al. presented evidence
ated with violation of one or more of three basic
that improvements in IC practices were associprinciples of IC: (a) handwashing, (b) vaccination
ated with reductions in incidence of healthcareof healthcare workers, and (c) prompt placement
associated infection and exposure to communicable
of infectious patients into appropriate isolation
diseases among healthcare workers in hospitals
(Sepkowitz, 2004). Similar research has not been
and nursing homes (Haley et al., 1985). Occupaconducted in home healthcare, however. It is not
tional transmission to healthcare professionals in
known how many home healthcare clinicians
acute care settings (and implications for the pohave acquired a healthcare-associated infection
tential risk to family members of the healthcare
or whether these infections have been transmitprofessional) has been identified (Sepkowitz &
ted to their household members. Nor are there
Eisenberg, 2005) for numerous diseases, including
any studies that have examined timeliness of
infections caused by blood-borne organisms
communication by the agency to the frontline
(human immunodeficiency virus [HIV], hepatitis B
clinician of their patient’s status regarding invirus, hepatitis C virus, Ebola virus), organisms
fection or colonization with an MDRO. Table 1
spread through the oral–fecal route (salmonella,
lists some infections healthcare workers may
hepatitis A virus), and organisms spread through
vol. 30 • no. 4 • April 2012
Home Healthcare Nurse
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237
acquire; this list is not exhaustive, and not all
infections listed are common in all geographic
areas.
The Home Healthcare Environment of Care
Much of the IC research in home healthcare has
focused on prevention of infections related to
invasive patient devices (e.g., urinary catheters,
intravenous catheters) or wound care, rather
than the environment and patient care equipment (Safdar & Abad, 2008). One study (Zwanziger & Roper, 2002) was identified that examined
the home healthcare environment. Investigators
cultured 47 wound care supplies, including gauze,
normal saline, and scissors and wound measuring guides, for home healthcare patients at baseline, Day 7, and Day 14. Pathogenic organisms
were found on all 47 supplies at both Day 7 and
Day 14, including S. aureus and Enterococcus, and
there were more organisms at the 14-day time
point. There was no determination of whether
the organisms were drug-resistant. The researchers noted that the homes in their study ranged
from “filthy to clean” (Zwanziger & Roper, 2002).
Anecdotal evidence from practicing home healthcare nurses indicates that some change how they
manage patient-related supplies based on the
perceived cleanliness of the home. However, a
home that appears visually clean could be widely
contaminated with pathogens, some of which
may be drug-resistant.
There is also a long-standing controversy in
home healthcare regarding nurses’ bags. These
are the containers that are carried from home
to home, used by home healthcare nurses to
transport blood pressure cuffs, gloves, supplies
for venipuncture, and other items. Other clinicians may use similar bags to transport their
discipline-specific supplies and paperwork. HHA
policies about nurses’ and other clinician bags
vary widely (Davis & Madigan, 1999), ranging
from recommendations for clinicians not to bring
supply bags into patient homes to recommendations that clinicians place a barrier (e.g., newspaper) beneath the supply bag in the patient homes
to prevent “contamination.” One study (BakunasKenneley & Madigan, 2009) generated evidence
that nurses’ bags may serve as reservoirs for
multiple-drug-resistant pathogens, suggesting a
potential risk for indirect transmission of infection from one patient to another via a contaminated nurses’ bag.
238
Home Healthcare Nurse
Purpose
The purpose of this exploratory study was twofold: First, to determine the number of home
healthcare clinicians diagnosed with an occupationally acquired infection caused by an MDRO,
and among clinicians who have had these infections, whether the infection was transmitted to
any of their own household members. Second, to
describe HHA policies and procedures related
to infection prevention and control.
Research Questions
The specific aims of this study were to generate
useful information for infection prevention and
control measures specific to the home healthcare
setting.
1. How many home healthcare clinicians have
had a diagnosed occupationally acquired
infection?
a. Among those who have had these infections, was the infection transmitted to any
of the clinicians’ household members?
b. If so, how many?
2. How does the HHA communicate to clinicians when their patients are colonized or
infected with MDRO?
3. What are the HHA IC policies for:
a. Isolation of patients colonized with
MDRO, or with diagnosed MDRO infections?
b. Use of dedicated medical equipment for
patients with diagnosed MDRO infections?
c. Patient and family teaching about prevention and control of MDRO?
4. Do home healthcare clinicians take their
equipment bags (nurses’ bags) into homes of
patients with diagnosed MDRO infections?
5. Do HHAs employ full-time IC nurses?
Methods
This was an exploratory descriptive study using a
researcher-developed 22-item survey. Survey questions were pilot tested by two groups of five home
healthcare clinicians (n = 10) to identify any problems in clarity, to refine it if needed, and to time the
instrument. The groups also reviewed the survey
for face validity and feasibility. Questions were constructed to be neutral, simple, free of ambiguity,
and to encourage accurate and honest responses.
Participants had the option to include narrative
comments. With this careful pretesting we con-
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cluded that the survey possessed a considerable
degree of representativeness. Survey solicitation
was conducted from April 2009 to January 2010.
Multiple methods were used to recruit home
healthcare clinicians to complete the survey to
achieve a representative sample. First, a mailing
list was purchased from the journal Home Healthcare Nurse and surveys were mailed to 3,800
practicing home healthcare clinicians—the participants could complete and send back the hard
copy version or complete the survey online.
Second, an advertisement was placed in the journal Home Healthcare Nurse with a link to the online survey. Third, the surveys were added to the
handouts at the September 2009 Ohio Council for
Home Care and Hospice annual conference in
Columbus, Ohio; approximately 100 surveys were
distributed. To the researcher’s knowledge, this
is the first national survey of home healthcare
clinicians about IC practices.
The participants responding via postal mail
were sent an instruction page with a description
of the purpose of the study and how the data will
be used. Completion and return of the survey
was considered consent to participate in the
study. For those responding via the Internet, an
instruction page appeared before any survey
questions. An affirmative response to an item
indicating the participant read the instructions
and agreed to participate was mandatory to be
able to continue on to the survey questions.
Figure 1. Age of respondents.
40%
n = 174
35%
30%
n = 116
25%
n = 84
20%
15%
n = 40
10%
5%
0%
n=6
20-30
31-40
41-50
51-60
>60
Figure 2. Status as a clinician for respondents.
0.90%
0%
4.5%
1.30%
0%
Clinician Type
RN
n = 389
LPN
n = 20
HHC Aide
APN
92.4%
n=0
n=4
Physical n = 6
Therapy
Results
Demographics
A total of 423 home healthcare clinicians completed surveys, reflecting an approximate response rate of 9.2%. However, the exact number
of persons reached by the combination of recruitment methods is unknown. For this sample
(n = 423), zip codes showed participation from
44 states, including Alaska and Hawaii. The
highest number of responses was the same from
two regions, the Midwest (n = 153) and Northeast
(n = 153). The Southern region had the second
largest response (n = 112).
Figures 1, 2, and 3 illustrate the characteristics
of the survey respondents. An overwhelming
majority of participants were female registered
nurses (92.4%) between the ages of 51 and 60
(typical of many healthcare settings [Hill, 2011]).
Most participants had previous jobs in acute
care hospitals (see Figure 3), and were relatively
vol. 30 • no. 4 • April 2012
Notes: APN = advanced practice nurse; HHC = home healthcare;
LPN = licensed practical nurse; RN = registered nurse.
health conscious, with 78% (n = 322) of respondents reporting having had a physical examination within the last 12 months (Figure 4).
Occupationally Acquired Infections
Among this sample of home healthcare clinicians, 5.91% (n = 21) reported that they were
diagnosed with an occupationally acquired infection caused by an MDRO (Table 2). Of the clinicians reporting infections, none reported that
the infection was transmitted to any of their
household members. Diagnosis was confirmed
with microbiological culture in 71.4% (n = 15) of
cases, and by physician assessment and other
laboratory testing in the remaining 28.6% (n = 6)
Home Healthcare Nurse
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239
Figure 3. Responses to question: “Did you work
in an institutional setting before working in home
healthcare? If so, what type of institutional setting?”
HHA Infection Control Policies and
Procedures
Previous experience
Other*
Rehab
center
n = 24
n = 10
Nursing
home
n = 15
Hospital
n = 368
0%
20%
tion is infrequently used to communicate patient
infection status (2.4-7.1%).
40%
60%
80%
100%
*Responses for “Other” category: Home care for pediatrics/infusion, freestanding Ambulatory SurgiCenter, home healthcare, outpatient rural clinic,
public health, biotechnology/pharmaceutical, clinic.
of cases. The majority of reported skin and soft
tissue infections (SSTIs) were caused by MRSA at
76.2% (n = 16). The second most frequent infection reported (33.3%, n = 7) was gastrointestinal
(GI), caused by Clostridium difficile. An unexpected result was 4 of the 21 clinicians reporting
infections indicated they had both MRSA and C.
difficile infection. Two respondents (9.5%) indicated they had sustained a needle-stick injury
and had acquired hepatitis B. Treatment for the
SSTIs was oral antibiotics, nasal spray bactroban,
or intravenous antibiotics, and treatment for the
GI infections was oral antibiotics.
Table 4 details HHA policies and procedures
regarding infection prevention and control as reported by survey respondents. A little more than
half (59.5%) of clinicians reported that their
agency did not have a written policy regarding IC
precautions for care of patients colonized with
MDRO, while slightly more than two-thirds
(69.5%) reported that their agency did have a
written policy regarding IC procedures for patients diagnosed with MDRO infection.
About two-thirds of clinicians (62.8%) reported
their agency did have a written policy for use of
dedicated equipment for patients with diagnosed
MDRO infection. The types of equipment that most
frequently remain in the patient home include
stethoscope and blood pressure cuff (Figure 5).
More than three-fourths (76.2%) of clinicians reported that their agency did have a written policy
regarding patient and family teaching for infection prevention and control. Only about one-half
(47.6%) of clinicians reported they did not take
their nurses’ bag into the homes of patients with
diagnosed MDRO infection, whereas the other
half (52%) reported that they did this at least
sometimes. More than three-quarters of participants (79%) indicated they do not have a full-time
Infection Preventionist (IP) at their agencies, and
for those that do employ an IP, 33.3% have other
jobs and duties within the agency.
Communication of Patient MDRO Infection/
Colonization to Frontline Clinicians
Strengths and Limitations of the Study
Study results show that when patients are admitted to the HHA with a known MDRO infection,
communication of this status to frontline clinicians is primarily written (73.8%), although verbal communication takes place as well (59.5%).
Less written (59.5%) and more verbal (66.7%)
communication occur when patients are diagnosed with an MDRO infection after home healthcare admission (Table 3). Communication of
patient infection status by flagging the patient
chart occurs in a little more than one-third of
agencies (38.1%), according to clinicians, both
when infection is known at home healthcare
admission and when infection is diagnosed following admission. Clinicians reported that colorcoding patient record according to type of infec-
The approach taken to examine this topic is a
strength of this study. This is the first national
survey of home healthcare clinicians about
agency policies and procedures for MDRO infection prevention and control, and it is the first
study to identify the prevalence of occupationally acquired MDRO infections among home
healthcare clinicians. The use of survey methodology allowed the investigator to rapidly reach a
large population of home healthcare clinicians
across a wide geographical area. Further, this
method assures respondent anonymity. This
study has several limitations that should be
noted. First, a survey only collects self-reported
data, which may not be completely reliable. Respondent recall may be selective, or they may
240
Home Healthcare Nurse
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Figure 4. Date of respondents’ last visit to primary care provider (n = 414).
6 months to a year
>1 year
>2 years
>3 years
16.1%
n = 72
4%
n = 18
0.4%
n=2
78%
n = 322
not have been willing to express their beliefs or
attitudes on infection prevention and control topics. In addition, responses to this survey may not
be generalizable to the all home healthcare clinicians because clinicians who completed and returned the survey may differ in some way(s) from
clinicians who did not complete the survey. Finally,
the survey obtained clinician report of agency
policies and procedures; no direct examination
of actual policies and procedures was done.
Discussion
Healthcare-associated infections are responsible
for significant morbidity, mortality, and undesirable economic consequences in the United States.
Reducing the incidence of healthcare-associated
infections and protecting patients, clinicians, and
caregivers will require a collaborative response
that crosses all settings where healthcare is delivered. This response must include emphasis to
improve communication during transitions
among healthcare settings when MDROs are involved. Standardization of infection prevention
and control practices with emphasis on the flexibility necessary in the home healthcare setting
while maintaining proper technique is needed.
Infection prevention and control educational programs for frontline clinicians need to be provided
on an ongoing basis. These educated frontline
vol. 30 • no. 4 • April 2012
clinicians can then teach their patients/families
about standard precautions, handwashing and basic
infection prevention, teaching them what they
need to know when no other help is available.
This exploratory study was intended to provide the groundwork for further research in this
area. The occurrence of occupationally acquired
infections involving MDROs was very small in
this study; however, this presents an opportunity
for action rather than reaction. Today, patients
are discharged from institutional settings where
invasive devices and high-tech care is commonplace sooner and sicker. It cannot be denied that
the risk of occupationally acquired infections
exists and is a consideration in daily patient care.
The wide variation of infection prevention practices reflected in this study shows there is disagreement among home healthcare professionals
about the environment of care and patient/employee safety practices. Contact isolation is not
required in some of the participants’ agencies,
but this issue has immense public health implications underscoring the need for standardization
of infection prevention practices. Occupationally
acquired infections cause considerable illness
and occasional deaths among healthcare professionals (Sepkowitz, 2004). Further studies in home
healthcare are needed to enhance compliance
with established IC practices.
Home Healthcare Nurse
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241
Table 2. Survey Respondents With Occupationally Acquired Infection (5.9%;
n = 21), Type of Infection, Method of Diagnosis, and Treatment
Organism
MRSA
Clostridium difficile
Otherb
Type of Infection
Confirmatory
Microbiology
Cultures
Physician
Assessment (and
Other Lab Tests)
Treatment
SSTI
76.2%
(n = 16)a
71.4%
(n = 15)
28.6%
(n = 6)
Antibiotic (oral, intravenous,
and nasal spray bactroban)
GI infection
33.3%
(n = 7)a
Not applicable
100% (n = 7)
Antibiotic (oral)
Hepatitis B
9.5%
(n = 2)a
No information
No information
No information
GI = gastrointestinal; MRSA = methicillin-resistant Staphylococcus aureus; SSTI = Skin and soft tissue infection.
aThere were four respondents who stated they had both MRSA and Clostridium difficile.
bNeedlestick injury.
Table 3. Communication Method of Patient Multiple-Drug-Resistant
Organisms (MDRO) Infection/Colonization to Frontline Clinicians
Verbal
Written
Chart
Flagged
Chart
ColorCoded by
MDRO Type
Other
If a patient is admitted to your home care agency with a
known MDRO infection/colonization, how is this information
communicated to the frontline clinicians? (Choose all that apply.)
59.5
73.8
38.1
2.4
23.8*a
If a patient is diagnosed with MDRO infection or colonization
only after admission, how is this information communicated to
the frontline clinicians? (Choose all that apply.)
66.7
59.5
38.1
7.1
23.8b
Survey Question
Note: Data in the table are represented as percentages.
aOther responses included: “electronic care plan and written on order, chart flagged via computer record, entered into electronic medical record (EMR),
noted on clinical record on laptop computer, all patient records are electronic so we are notified/flagged, agency uses EMR … always current, downloaded
between patients, profile in laptop is marked.”
bOther responses included: “electronic care plan and written on order, chart flagged via computer record, entered into the EMR, noted in the laptop
computer, discussed at our weekly team meeting, agency uses EMR … always current, downloaded between patients, profile is marked, in patient’s
computer record, not always communicated.”
Implications for Practice
1. Standardization of Infection Prevention
and Control in Home Healthcare
According to the survey responses, there is a
great deal of variation in infection prevention and
control practices in the field; standardization of
practices in home healthcare must become a prioritized concern. Patient homes are unique environments for provision of healthcare and may be
lacking in space or resources for straightforward
IC practice. Administrative measures must make
infection prevention and control an agency priority. Administrative support is needed for both
fiscal and human resources to prevent and control transmission of organisms. Further adminis-
242
Home Healthcare Nurse
trative measures include the implementation of
systems to communicate information about reportable MDROs to administrative personnel and
state/local health departments. A process is required to designate patients known to be colonized or infected with targeted MDROs, communicate this status to frontline clinicians treating
these patients during home healthcare, and to
notify receiving healthcare facilities or personnel
prior to transfer of these patients to other settings (Lee & Garvin, 2003; Moore et al., 2003). A
multidisciplinary team approach should be used
to monitor and improve clinician adherence to
recommended practices for standard and contact
precautions. Annual feedback should be provided
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Table 4. Infection Control Policies and Procedures
Survey Question
Yes
(%)
No
(%)
Do Not
Know (%)
Does your agency have a written policy for isolation of patients known to be
colonized with an Multiple-Drug-Resistant Organism (MDRO)?
26.2
59.5
14.3
Does your agency have a written policy for isolation of patient diagnosed with an
MDRO infection?
69.5
28.6
11.6
Does your agency have a written policy for use of dedicated equipment?
62.8
30.2
7.0
Does your agency have a written policy for teaching to the patient/family or other
caregivers about prevention of the spread of MDROs?
78.6
16.7
7.1
Do you take your nurses’ bag into the home of a patient with a known MDRO
infection?
Sometimes
31.0
47.6
21.4
Does your agency employ a full-time infection prevention and control nurse?
21.4
78.6
N/A
If you answered “yes” to the above question, does the infection prevention and
control nurse have other job duties/titles within the agency?
33.3
4.2
N/A
to clinicians and administrators on infections
caused by MDROs, concentrating on changes in
prevalence and incidence, problem assessment,
and ongoing performance improvement plans.
2. Ongoing Education About Infection
Prevention and Control
Successful implementation of infection prevention and control in the home healthcare setting
depends in part on educating frontline clinicians
on an ongoing basis (e.g., annual reviews) so they
thoroughly understand IC policy and procedures.
Clinicians have to be able to implement infection
prevention and control practices correctly and
consistently in patient homes, and also have to
be able to effectively teach patients and their
caregivers to do the same. Education and training for clinicians must be provided during orientation, and periodically thereafter, for example,
as annual competencies. Strategies for effective
patient and caregiver teaching should be addressed, as well as methods for evaluation of
patient and caregiver implementation of infection
prevention and control practices.
3. Addressing the Home Environment and
Cleaning
As an aid in standardization of care and cleaning of
the home, the Environmental Protection Agency
(EPA), Occupational Safety and Health Administra-
vol. 30 • no. 4 • April 2012
tion (OSHA), and the CDC provide a comprehensive infection prevention and control program with
a section for home healthcare (HICPAC, 2007). Ongoing education of clinicians, patients, and caregivers must include product use and appropriate disinfection practices for linens, household supplies,
and the home environment. Education should
focus particularly on cleaning and disinfection of
frequently touched surfaces such as bedside commodes, bedside tables, doorknobs, and equipment
in the immediate vicinity of the patient. Environmental disinfection should be a priority practice
for patients on contact precautions.
Noncritical medical equipment and other patient care items for individual patients known to
be infected or colonized with an MDRO should be
left in the home. These are called “dedicated”
medical items, and may include stethoscope,
blood pressure cuff, and wound care supplies. The
amount of items brought into the home should be
limited. If noncritical items cannot remain in the
home, clean and disinfect items before removing
them from the home, using a low-to-intermediate
level disinfectant, or place reusable items in a
plastic bag for transport to another site for subsequent cleaning and disinfection.
4. National Benchmarking
There is a documented risk of infection in the
home care setting (Manangan et al., 2002). With
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243
Figure 5. Type of dedicated equipment used in
homes of patients diagnosed with multiple-drugresistant organism infection.
Other*
n = 50
Pulse Oximeter
n = 11
Blood Pressure
Cuff
n = 115
Stethoscope
n = 119
0
10
20
30
40
50
60
70
80
90
*“Other” dedicated equipment responses included pumps, dynamap pole,
thermometer, weight scale, Hommed, personal protective equipment and
shoe covers, gowns gloves and masks, any and all equipment for patient.
the continued expansion of home healthcare
delivery, a national system for surveillance of
healthcare-associated infections in the home
care setting is needed. The goals of a surveillance
system include patient safety and improving the
quality of patient care, as well as reducing morbidity and mortality associated with infections
(APIC, 2005). Surveillance in any setting must include the development of standardized definitions of infections and methods for identification,
reporting, and tracking infections. Individual
home care agencies have developed surveillance
definitions for their own use (Manangan et al.,
2002). National definitions of infections in home
care do not exist. The APIC issued draft definitions of home healthcare-associated infections,
but these have yet to be accepted and implemented at the national level (Manangan et al,
2002). Collaboration of home care agencies with
state and federal health agencies, private industry, and national or managed-care organizations
is essential to make this system feasible and
functional. A first step for home care agencies is
to designate a staff position for IC. Without the
requisite expertise, home care agencies have
limited resources with which to participate in
these efforts.
antibiotics has become a concern in all healthcare settings, and home healthcare is no exception. Home care agencies should consider
formation of a multidisciplinary team to develop
a process to review local susceptibility patterns
(antibiograms), and the antimicrobial agents
used to foster appropriate antimicrobial use.
Agency management teams should be provided
with susceptibility reports and analysis of current trends, updated on an annual basis due to
the changing patterns of resistance of MDROs.
Agencies generally outsource microbiology
laboratory services and must specify by contract that the laboratory provide either agencyspecific susceptibility data or local or regional
aggregate susceptibility data to identify prevalent MDROs and trends observed in the geographic area.
With leadership from an IP, home healthcare
agencies can develop appropriate infection prevention and control policies and procedures and
education for frontline clinicians. In agencies
that have limited electronic communication,
implementation of a process to review antibiotic use and the preparation and distribution of
reports to providers is a minimal requirement.
Antibiotic stewardship programs may become
mandatory in institutional settings in the near
future (File, 2010), and home healthcare is sure
to follow.
5. Antibiotic Stewardship
Irena Kenneley, PhD, APRN-BC, CIC, is an Advanced Practice Clinical Nurse Specialist in Public
Health Nursing and an Assistant Professor and Research Scientist at the Frances Payne Bolton School
of Nursing, Case Western Reserve University, Cleveland, Ohio.
This research project and manuscript would not
have been possible without the support of many
people. The author wishes to express her gratitude
to her colleague and friend, Assistant Professor
Jennifer Riggs from the University of Alabama at
Birmingham School of Nursing, who was abundantly helpful and offered invaluable editorial
guidance and support.
The author declares no conflicts of interest.
Address for correspondence: Irena Kenneley,
PhD, APRN-BC, CIC, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-4904
(ilz@case.edu).
Overuse and misuse of antibiotics have resulted
in the evolution of MDRO—monitoring the use of
DOI:10.1097/NHH.0b013e31824adb52
244
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www.homehealthcarenurseonline.com
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