New, improved ‘reality-based infection control’

3 steps to infection control accreditation

ABC Agency in Tennessee had a Joint Commission survey scheduled for Monday. Sunday night, the surveyor sat in her hotel room reading the agency’s policies and its procedure manual. The next morning, she arrived at the office and told the agency director she was going cite the organization. "Why?" asked the director. "Because," said the surveyor, "according to your own policies, you are required to pick up road kill and old mattresses, but you have no procedure that relates to those issues."

"The policy was a holdover from when the agency had a public health role in a very rural community," says Judy Adams, RN, BSN, clinical coordinator at J&G Consultants in Raleigh, NC, a consulting firm that specializes in home care consulting and survey preparation. "No one had reviewed the total policy in about 20 years. They just kept adding to it and adding to it."

Adams says many agencies make the mistake of assuming that just having a policy is enough. This is particularly true in the area of infection control. Agencies may have infection control policies that look good on paper but do not conform to the everyday situations staff members face. "You have to have a realistic policy that people know and use," Adams says. "If you don’t, there is no point."

Lillia Rosenheimer, MPA, RN, associate director of nursing at Community Home Health in San Pablo, CA, agrees. "Something similar happened to us," she recalls. "We had purchased someone else’s procedure manual for $500, but no one had read it. One of the policies called for the nurse to put on an apron as soon as she arrived at the client home. But no one does that any more. If you don’t read your own policies and procedures, you are going to get into trouble."

Adams says your agency can take the following simple steps to make sure your infection control policies are both effective and realistic:

1. Focus on key issues.

The more complex and in-depth the policy manual, says Adams, the less likely it is to be followed. "Five pages on every little step you take is not going to be very useful," Adams says. "You really only need to concentrate on equipment transportation, hand washing, and bag technique."

For equipment, adopt a two-color bagging system. One color — white, for example — can be used to transport dirty equipment or supplies. Once something is used, it is put into the white bag. Another color — yellow or clear — can be used for clean gear. Medical devices that shouldn’t roll around in a vehicle can be kept in a large covered plastic box. This keeps it clean and contained. Even a cardboard box will do in a pinch, she says.

Ensure knowledge of minimum requirements

Hand washing is an area where many agencies develop a religious fervor. "Hand washing is vital, but if you have a policy that is too complicated, what’s the point?" asks Adams. "It has to be a rational policy. If you tell people they have to wash their hands for a full minute, 10 times a day, no one will follow the policy."

Instead, make sure staff understand the minimum requirements. "We say they have to have 10 seconds of washing with soap and warm running water. All our staff carry liquid antibacterial soap and paper towels at the tops of their bags."

Proper bag technique is best cultivated through inservices and supervised visits, says Adams. The proper technique is demonstrated at the inservice, and employee capabilities are assessed during supervised visits. "If you see any breaks in technique, you can institute corrective action right away."

2. Don’t worry about unlikely infections.

Many agencies try to monitor every possible type of infection. This is a waste of time, says Adams. "If you don’t have a lot of Foley catheters, why monitor bladder infections?"

"It’s best to focus on issues that relate to the population you serve," says Freida Embry, RN, director of risk management and infection control for Lifeline Home Health Care of Somerset, KY. "If you have a high dialysis population, then network with dialysis staff to reinforce teaching on those issues."

Rosenheimer and Embry have been working on a study of four agencies’ infection surveillance programs that compares infection rates among the agencies. This type of information is extremely hard to find, says Rosenheimer, but very useful when available. (See related story on starting an infection control program, p. 6.) "It can let you know whether your rates are within the norm," she says. Rosenheimer plans to publish the study in 1997.

3. Evaluate policy effectiveness.

Once you have a policy in place, you can’t just assume it works, says Embry. "People see policies as a way to accommodate some government or agency requirement," she says. "But they never evaluate their effectiveness."

For example, her company had a policy that required all staff to carry an extra set of clothes with them in case the clothes they wore were contaminated by blood or other body fluids that might contain a pathogen. "We looked at the reality, and found that two years after the policy was implemented, very few people were following it. You have to make sure a policy takes reality into account." Now, there is a new policy that calls for staff to carry two isolation gowns in their vehicle for emergency use. This policy is being followed, says Embry.

Much of this evaluation has to center on how realistic a policy is, says Embry. "If you try to have an ideal situation, you won’t be able to get families to follow the rules," she says. "Your policy can be sabotaged. But if you acknowledge that a family member is going to reuse a suction catheter, then you can develop a safe mechanism for them doing that. That is reality-based infection control."

Whatever your policies, says Rosenheimer, make sure you go over them regularly — at least once a year, although preferably as often as you make changes. "Make sure what you have written down and what you actually do in the field are the same," she says. "Problems arise when you don’t know what your own policies say."