Select the right infection control data to benchmark

Quality managers offer guidelines

Home care agencies are seeing sicker patients these days, and increasing numbers of patients are infected with drug-resistant diseases.

So it might be time for your agency to put together an infection-control benchmarking program that would comply with all accreditation and regulatory standards.

A first step will be to select which infections to track, say quality managers who have started the benchmarking process. But before you can select infections to track, you need to collect some preliminary data so you can answer these three questions:

• How many different diseases does your agency see?

• What percentage of your patient population has each disease?

• Which diseases place staff and patients at high risk for harm because the disease is deadly or untreatable?

Quality managers offer these tips on selecting infection control data:

1. Identify your patients’ most common infections.

Columbia Homecare Oklahoma of Claremore, OK, collected data on every infection the agency’s patients had in 1996. (See story on how to collect infection control data, p. 107.)

The agency came up with 25 different infections, including ear infections, eye infections, and tick bites, says Stella M. Dotson, RN, MS, continuous quality improvement coordinator for the agency, which is part of the Columbia Health System in Nashville, TN.

Columbia’s 29 home care agencies in Oklahoma recently started to work together to benchmark infectious diseases.

"The top three infections we found with patients were urinary tract infections, upper respiratory infections, and wound infections," Dotson says.

These three infections represent a good place for all home care quality managers to start because they are so common, says Linda Baker, RN, continuous quality improvement coordinator of Columbia Homecare Oklahoma of Tulsa, OK.

"I think you’d probably find this in most home care agencies because of the age group we’re dealing with," Baker says.

Although these three infections are common, they typically do not place staff and patients at very high risk because they can be easily treated, she says.

The most common infections also are the most likely to spread between patients and staff, says Sharon Link, RN, BSN, quality management supervisor for Allied Home Health of Scranton, PA, a full-service, nonprofit agency that serves northeastern Pennsylvania.

"So if you have a high volume of wound infections, there is a higher potential you could take that infection from one patient to the next," Link explains.

Also, Link says, a high volume could mean you need to give your staff more education on infection control measures.

2. Decide which dangerous diseases to study.

Link insists that quality managers must know the population of patients that their agencies serve. Here’s how you do that:

• First check with your local health department and state health department to find out which infectious diseases are a public health threat in your community, Link says.

• "Then you want to identify the infectious diseases that place patients and employees at risk," Link says.

These could include tuberculosis, vancomycin-resistant enterococcus (VRE), and methicillin-resistant Staphylococcus aureus (MRSA). (See quick guide to TB, VRE, and MRSA, p. 111.)

Ask state health department for TB data

• Check the incidence rate for each infectious disease. "Look at the area you live in, and see what the rate of TB is," Link suggests as an example. Since TB has become resistant to multiple drugs in some people, it also would be a good idea to check on what strains of drug-resistant TB are appearing in your area.

"The state health department can tell you how many people per the [general] population have TB, and they can tell you per county what the incidences are," Link states.

Link says other agencies may include AIDS, hepatitis B, and hepatitis C on this list, depending on their answers to those three questions. "You’ve got to know which diseases your area has. Are they found in a high percentage of your patient population? Do they place your patients at a high risk?

"Sometimes you might have a small number of patients with a disease, but because the effects of the disease are so devastating, you’ll need to study it," Link says.

Link mentions AIDS patients as an example. Her agency has only treated one or two AIDS patients in recent years, and the patients weren’t treated specifically for AIDS. So her agency has less reason to be concerned about AIDS than do agencies that routinely treat AIDS patients.

"You will have some agencies that do a lot of home infusion on AIDS patients, and that’s a big risk," she says.

However, if the agency’s home infusion department grows and more people with AIDS were being seen by the agency, then AIDS might become a priority, she adds.

3. Select your agency’s medical procedures that place patients at high risk for infection.

The quality managers suggest home care agencies monitor patients who have central lines, peripherally inserted central catheters, urinary tract catheters, IV central lines, and suprapubic catheters.

"Look at the patients who have a ventilator or any invasive device," says Lilia Rosenheimer, RN, PHN, MPA, director of Community Home Health Care of San Pablo, CA. The full-service, hospital-based agency conducts 36,000 visits a year in the Bay area of northern California. It’s part of the Tenet Health System of Santa Barbara, CA.

"Any time you have a device in, you have an increased risk of infection," Rosenheimer says.

Home care agencies also need to find out whether the patient had been using an invasive device before being discharged from the hospital, Dotson says.

"If they have a catheter in the hospital and came home with no catheter, but later came down with a urinary tract infection, then the infection might track back to the catheter," she explains.

4. Monitor occupational exposures to infectious diseases.

"You need to monitor positive [purified] protein derivative tests [for TB] and educate patients and employees on the spread of infectious diseases," Link states.

Dotson says Columbia Homecare requires staff to take the TB skin test every year. The agency had one aide and a nurse who tested positive for TB during one year’s exam, although they had tested negative the year before. (See story on choosing indicators, p. 109.)

Dotson and Link say nurses could expose themselves to infection through accidental needlesticks. Similarly, a patient’s bodily fluids could splash and come in contact with the employee’s mucous membranes.

The best way to handle these accidents is to send the employee immediately to the emergency room for a blood test, Dotson says. Her agency has employees tested for HIV and hepatitis B.

Then if the test comes back negative, the employee is retested at three months, six months, and one year post-exposure.

Columbia Homecare has followed about five employees who were exposed to infectious diseases, and all of them tested negative a year after the exposure, Dotson says.

Link suggests quality managers identify the occupational exposures defined by the Occupa tional Safety and Health Administration of Washington, DC. Every agency already must track these infections, she adds.