Track infection control to minimize troubles

Here’s how one agency tackled the job

Tracking infection control problems in home care might be a little like trying to count beaks in a flock of migrating birds.

But as tricky as the task might seem, it can be done through a careful quality improvement process. Done correctly, thorough surveillance could lead to better infection control outcomes.

For instance, a Lexington, KY, agency has found through tracking infection rates that it is unnecessary for the agency to pull cultures from wounds of every patient and then treat them with antibiotics. "Our medical director is adamant that you very rarely culture wounds," says Casey Hamblen, RN, QA specialist for Saint Joseph Home Care Services in Lexington. The hospital-based agency serves a six-county area around Lexington.

"He’s on the conservative side as far as treatment and I’ve seen a significant decrease in the number of wound cultures we do, but we still have the same rate of healing," Hamblen says.

Nurses follow the new philosophy by not calling a patient’s doctor unless the patient’s wound meet the infection criteria the agency adopted as part of its new surveillance program. For example, cloudy urine doesn’t meet the criteria for a urinary tract infection because this could also be a sign of some other problem, such as a change in hydration. But if the patient is feverish and also has cloudy urine, this does meet the infection criteria.

This was a major shift in the agency’s culture because traditionally patients were treated more liberally. This created an environment conducive for antibiotic-resistant bacteria to flourish. "Patients would get resistant organisms because the doctor treated them with two to three different antibiotics and the organism would [infect] a wound and be impossible to treat," she adds.

Without having a good surveillance program in place, the agency wouldn’t have realized that a more conservative treatment regimen could lead to the same positive outcomes.

Secrets of St. Joseph

Saint Joseph Home Care Services started its in-depth infection surveillance program two years ago with these steps:

1. Seek expert help.

"I was very fortunate because our medical director happens to be an infection disease doctor and was an excellent resource," Hamblen says. "He helped me come up with the idea that we needed to develop a way to have patient days and device days so that our numbers made sense to people."

For every device used, Hamblen broke it down by devices, such as an indicator for how many days a patient had on a Foley catheter.

Other indicators were:

How many patient days?

How many days for intravenous lines?

How many days for tracheostomy tubes?

While the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations recommends that agencies monitor all infections, the agency decided to report only home health care-related infections.

"Before that I was reporting everything, including ear infections," Hamblen says.

And while the agency still looks for specific infection trends that are unrelated to devices — such as a spread of bronchitis if a particular nurse has bronchitis — for the most part the surveillance tracks only infections that clearly could be related to home health care treatment.

The medical director also steered Hamblen to finding infection definitions in literature published by the Atlanta-based Centers for Disease Control and Prevention (CDC). (See sample of CDC’s infection definitions, p. 87.)

Hamblen wrote the agency’s infection definitions according to 1988 CDC criteria for nosocomial infections. These criteria included definitions for:

surgical wound infection;

primary bloodstream infection;

urinary tract infection;

bone and joint infection;

cardiovascular system infection;

central nervous system infection;

eye, ear, nose, throat, and mouth infection;

gastrointestinal system infection;

lower respiratory tract infection (excluding pneumonia);

reproductive tract infection;

skin and soft tissue infection;

systemic infection.

Hamblen’s last step was to develop a surveillance plan that outlined how the data would be collected and reported, and which definitions would be used. (See infection surveillance plan, p. 87.)

2. Develop surveillance tools.

The agency’s new infection report form is a simple, one-page form with places for nurses to put check marks next to the site of infection, signs and symptoms noted, and the current status of the patient. (See Saint Joseph’s infection report, inserted in this issue.)

The agency also uses a patient device control report, which also is a simple, one-page form. This report lists the various devices and has a spot for up to five patient identification numbers, the number of days the device was in place, and whether an infection was noted. (See patient device control report, inserted in this issue.)

Since the agency is small and its documentation is not entirely electronic, nurses fill out the forms on paper and Hamblen keeps a paper log, listing the patient’s name, the nurse’s name, the onset date of infection, the site of infection, and how it was treated.

She has also started to use a census field on her computer to track which patients had devices and the dates those devices were put into place.

Finding a shortcut

Each month, Hamblen adds up the infection numbers and indicators’ data and reports them to the agency’s quality assurance committee and medical director.

But most of her surveillance work was done manually. "For six months, I read every order that our nurses wrote to see when patients were put on antibiotics," Hamblen says. "Now we have a method where if a director, who receives copies of all prescription orders, sees an order with an antibiotic, she copies that and gives it to me."

3. Train staff and monitor infection control trends.

Nurses learned that they must follow the CDC definitions for infection and refer to the 1988 report if they had any questions.

For example, patients who have Foley catheters have a higher rate of urinary tract infections (UTIs). So the agency reinforced staff education about the correct techniques to use with patients on these devices.

"And we made sure everyone is treating according to the criteria for UTIs," Hamblen says.

Sometimes the nurses have no control over whether a patient is treated for a UTI because patients occasionally will treat themselves by calling their physicians, asking for antibiotics when they feel they might have an infection, she notes.

"In those cases we don’t know if they had a true UTI, but we document it as one," Hamblen says.

After collecting data each quarter and after one year, Hamblen gave a report on the trends and the results to the home care agency’s quality assurance committee, advisory board, and even to the hospital’s quality improvement committee.

She found no evidence that the agency’s nurses had problems with techniques and were causing infections, so there were no resulting QI infection control projects. However, Hamblen says, she continues to track all infections. "But I only write reports on the ones where we’ve had some impact."

(Editor’s note: For a copy of the "CDC Definitions for Nosocomial Infections, 1988," which is from the Hospital Infections Program, Center for Infectious Diseases, CDC, contact the National Technical Information Service, U.S. Department of Commerce, 5285 Port Royal Road, Springfield, VA 22161, order No. PB 88-187117.)

Sources

Janice Powers, RN, Director, and Lisa Place, RN, BSN, Quality Improvement Supervisor, Citrus Memorial Home Health Agency, 502 W. Highland Blvd., Inverness, FL 34452. Telephone: (352) 726-6671.

Casey Hamblen, RN, QA Specialist, Saint Joseph Home Care Services, One Saint Joseph Drive, Lexington, KY 38750. Telephone: (606) 278-3436.