Choose infection-control benchmarking indicators

Quality managers explain how

You might have a great plan for benchmarking your agency’s infectious disease program, but if you haven’t selected indicators, then the battle’s only half over.

Selecting an indicator is the hardest part, says Stella M. Dotson, RN, MS, continuous quality improvement coordinator for Columbia Homecare Oklahoma of Claremore, OK.

Columbia Homecare is in the process of setting up a systemwide benchmarking program that will include infection control data from Columbia’s 29 different home care agencies. The company’s benchmarking team has just begun the process. So far, no indicators have been selected, Dotson says.

The team will begin with a brainstorming session that identifies the agencies’ top problems. "We’ll find out what the staff’s problems are out in the field," she says.

What are the 10 most common problems?

Then the agency will put together a questionnaire and ask each quality manager to list the top 10 most common infectious disease problems, Dotson says.

"We haven’t done anything formal yet," says Linda Baker, RN, continuous quality improvement coordinator for Columbia Homecare Oklahoma in Tulsa, OK. "We’ve discussed it and have gotten approval from the agency directors. It’s been a matter of finding the time to contact everybody and meet and brainstorm and see what indicators we want to include."

Allied Home Health of Scranton, PA, has chosen indicators, but is unable to share them due to proprietary considerations. But the agency’s quality management supervisor, Sharon Link, RN, BSN, says quality managers can ask these questions:

• What services does your agency provide?

• What kind of patients do you serve?

• What kind of infections have your patients had recently?

• What can you do to reduce the spread of infection among patients and staff?

Then select your top priorities. If your agency handles only a couple of AIDS patients each year, then AIDS might not be a top priority. So you could rule out AIDS as an indicator.

The whole idea is to better protect your patients, Link says. "If you’re not protecting your patients then you’re just spinning your wheels."

Lilia Rosenheimer, RN, PHN, MPA, director of Community Home Health Care of San Pablo, CA, says an indicator could be written using the definition or diagnosis criteria for each infection.

Perhaps your goal is to write an indicator about infections in patients using urinary tract catheters, Rosenheimer suggests. Then you could write the indicator, using the definition for a bacterial infection of this nature. The indicator might refer to a blood culture that tests positive for bacterial infection.

Use CDC’s definitions

Quality managers write indicators using the criteria established by the Centers for Disease Control and Prevention in Atlanta. For example, the CDC lists the following laboratory criteria for diagnosis of hepatitis A: "immunoglobulin M (lgM) antibody to hepatitis A virus (anti-HAV) positive."1

The CDC’s case classification for a confirmed case is: "a case that meets the clinical case definition and is laboratory confirmed or, for hepatitis A, a case that meets the clinical case definition and occurs in a person who has an epidemiologic link with a person who has a laboratory-confirmed hepatitis A (i.e., household or sexual contact with an infected person during the 15-50 days before the onset of symptoms)."

So the indicator could be written as the following: "The person has a blood sample that tests positive for the immunoglobulin M antibody to hepatitis A virus."

Rosenheimer says she tends to choose indicators that relate to devices in patients because these account for most of the infection problems.

"I focused on foley catheters, suprapubic catheters," she says.

Larger agencies might break the indicators down even further by focusing on whether the patient has a central line catheter or a peripherally inserted central catheter (PICC). This would help the agency determine whether a certain type of catheter is associated with more problems, Rosenheimer says. "But you have to have a large program to do that."

Rosenheimer suggests quality managers measure infection rates of patients on devices by using the following methodology:

The rate of infection = the number of infections ÷ by the number of days the patient was on the device X 1,000.

The answer is given in terms of how many infections have occurred per 1,000 days of using the device. "It’s important we develop standardized definitions and methodology so people can compare apples to apples," Rosenheimer says.

She collected the number of device days by looking at patient charts to see how many days they’ve had IVs for each month.

"If you have a larger program and have an IV coordinator, then the coordinator could collect that information," Rosenheimer says.

Rosenheimer tested this method and compared her findings with results from three other agencies that used the same methodology. They found their infection rates were similar. Rosenheimer and the agencies submitted their findings in an article for American Journal of Infection Control.

Track PPD tests, results

Another natural indicator to select is the purified protein derivative (PPD) test for TB. Link says agencies could test all employees for PPD. If an employee tests positive for PPD, meaning the employee has been exposed to tuberculosis, then the agency should require further testing, including a chest X-ray to make sure the employee doesn’t have an active case of TB, Link says.

"If an employee has active TB, we don’t let them go near a patient," she adds.

The CDC has guidelines for testing health care staff for active TB, and the indicator could be the number of employees who were tested and how many showed signs of inactive TB vs. active TB.

Dotson’s agency TB-tests all employees each year. One year, two employees tested positive. "We sent them to the health department and gave them baseline chest X-rays," Dotson says. The employees weren’t infectious, so the agency monitors them each year to make sure they stay that way.

They no longer take the TB skin test, but they are questioned about whether they’ve experienced any signs or symptoms of tuberculosis. These include night sweats, unintentional weight loss, and coughing up bloody sputum. If they have any symptoms, then they’re given another chest X-ray; otherwise, they are given a chest X-ray every five years, Dotson says.

Quality managers also could write an indicator that measures the nosocomial infection rate, according to CDC guidelines.

The CDC regularly publishes updated guidelines on preventing nosocomial diseases in its Morbidity and Mortality Weekly Report.

For example, the Jan. 3, 1997, report offers "Guidelines for prevention of nosocomial pneumonia."2 These guidelines make the following recommendations:

• Provide staff education and infection surveillance.

• Agencies thoroughly clean all equipment and devices before sterilization or disinfection.

• Sterilize semi-critical equipment or devices.

• Use sterile water for rinsing reusable equipment.

• Sterilize reusable mouthpieces, tubing, and connectors between uses on different patients.

• Wash hands after contact with body fluids regardless of whether gloves are worn.

• Wear gloves for handling respiratory secretions or contaminated objects.

• Change gloves and wash hands after contact with a patient.

• Wear a gown if soiling with respiratory secretions from a patient is anticipated.

Any or all of these activities could be used as indicators.

Link suggests another indicator could say all diagnoses of vancomycin-resistant enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) will be monitored.

MRSA and VRE are being seen more commonly in home care settings as patients are sent home still sick with the diseases. (See story on TB, VRE, and MRSA, p. 111.)

Link says her agency has no trouble tracking the infections because a hospital liaison picks up information on all patients before they’re admitted to home care.

"Agencies that don’t have liaisons can have a problem," she says. "You have to know what you’re looking for when you see a culture report because the diagnosis doesn’t always flash out at you."


1. Centers for Disease Control and Prevention. Case definitions for infectious conditions under public health surveillance. MMWR 1997; 46 (No. RR-10):18.

2. Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR 1997; 46 (No. RR-1):46-51.