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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 www.homehealthcarenurseonline.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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- www.homehealthcarenurseonline.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 www.homehealthcarenurseonline.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 www.homehealthcarenurseonline.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 Home Healthcare Nurse Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 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 ([email protected]). Overuse and misuse of antibiotics have resulted in the evolution of MDRO—monitoring the use of DOI:10.1097/NHH.0b013e31824adb52 244 Home Healthcare Nurse www.homehealthcarenurseonline.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. REFERENCES Association for Professionals in Infection Control. (2005). APIC text of infection control and epidemiology. Washington, DC: Author. Agency for Healthcare Research and Quality. (2008, July). 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