APIC seeks new staffing formula as ICP duties continue to expand

Is it time to go to one ICP per 100 occupied beds?

A new formula for infection control staffing in a rapidly changing health care system is the subject of a complex, ongoing research project that is expected to underscore what many suspect: The old ratio of one infection control professional per 250 beds is woefully inadequate.

The study, which involves time and task surveys and re-surveys of 32 participating ICPs, is being conducted by the Association for Professionals in Infection Control and Epidemiology (APIC). Updating the project at the recent APIC conference in Minneapolis, researchers noted that ICPs are stretched thin over an increasing array of responsibilities. Infection control has expanded into a variety of different health care settings, including physicians’ offices, affiliated clinics, and long-term care. All the while, additional functions, including quality improvement, safety, employee health, and management of central services have been added to the traditional ICP program.

"We would like to devise some kind of formula that could be used by hospital administrators and infection control practitioners to determine what is an appropriate level of infection control staffing," said Marguerite Jackson, RN, PhD, CIC, FAAN, one of the leaders of the APIC research effort and director of education, development, and research at University of California in San Diego Health Care. "That is a very big order, and methodologically a very hard question."

Data may go to state licensing boards

But even if the project concludes that staffing for infection control should be upgraded — e.g., to one ICP per 100 occupied beds — the question immediately becomes: Who would enforce such an edict? The best bet may be state medical and health licensing agencies, because staffing issues are not typically addressed by the Joint Commission on Accreditation of Healthcare Organizations, Jackson told Hospital Infection Control.

"The Joint Commission makes a practice of being nonprescriptive about staffing, and this has been an issue that APIC has addressed with [them] many times," she said. "[But] if they become prescriptive about staffing for ICPs, they would have to be prescriptive for nursing, for pharmacy, for all of the other areas that they accredit. Now, state health departments in some states do play that role, because they are the ones who are prescriptive about staffing levels to remain a licensed facility. So state agencies may be the way to go if these data are useful in terms of getting some kind of regulatory [action]."

The issue is further complicated on several fronts, particularly because health care staffing woes are not limited to infection control departments, she says. "This is not unique to infection control; everybody wants more staff," said Jackson. "That is true across the board, and the nursing shortage is going to get worse and worse. [Nursing] is the donor’ pool for most infection control people."

Furthermore, a fully staffed infection control department might still find its efforts undermined by clinical staff shortages, which have been linked to increases in nosocomial infection rates. "The care providers who implement the risk reduction strategies are not the ICPs," Jackson reminded. "It is the direct care staff."

The longstanding benchmark of one ICP per 250 occupied beds was recommended by the Centers for Disease Control and Prevention’s Study on the Efficacy of Nosocomial Infection Control (SENIC) project, which was directed by Robert Haley, MD, now a professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas.¹ Though SENIC data were gathered in the 1970s, the ratio was first field-tested in a 1960s CDC program called the Comprehensive Hospital Infections Project. Following that pilot study of some five years, the SENIC project began examining the infection control staffing issue, Haley explained.

"In SENIC, we looked at occupied beds and found some really strong empirical evidence that less than one [ICP] per 250 beds was detrimental," he told HIC. "The hospitals that didn’t meet that did decidedly worse in terms of infection rates. The question is how to change that now. There are a lot of alternatives. One is to try to ratchet down the recommendation so it is one [ICP] per 100 beds."

But because there are no data yet to justify that recommendation, Haley argued instead that ICPs should target their resources to their most important problems. "Use targeted, objective-oriented surveillance and control to decide what are your biggest problems, and [focus] whatever resources you have on those," he said. "So then, if you don’t have enough resources to meet all of your problems, you can show the administrator which problems you are not meeting."

Many hospitals not meeting staffing ratio

In addition, amid the discussions of increasing infection control staffing, it is well to remember that many hospitals aren’t even complying with the recommended 1:250 ratio, Haley said. "They are clearly out in left field and probably putting their patients at severe risk," he said.

Though an advocate of ICP involvement in the nation’s exploding patient safety movement, Haley said ICPs must not be shifted from their core responsibilities to exclusively track medical errors. "You have to be careful there, because you are adding a new job," he warned. "You don’t want the infection control people to take that on in place of their infection control job. It clearly is an add-on activity. You still need at least one ICP per 250 beds or better. Beyond that, you need some [department] to respond to this growing medical errors problem. That is probably going to [result in] additional staffing, but the staffing and activity levels for that are not yet defined."

The ICP staffing issue also was addressed — or "finessed," as it were — in a 1998 consensus panel report on the infrastructure of a modern infection control program.² That panel noted that the amount and complexity of the ICP’s work has grown due to increased severity of illness of the patient population and more health care delivery beyond the hospital. The panel did not, however, suggest a new staffing formula or ratio, recommending instead that personnel resources for infection control and epidemiology in hospitals should be proportional to the size, sophistication, case mix, and estimated risk of the populations served by the institution.

"We finessed the issue of 1 per 250 despite a lot of insistent requests from the field that we put a number in there," William Scheckler, MD, panel chairman and hospital epidemiologist at St. Mary’s Hospital Medical Center in Madison, WI, told attendees at the APIC session. "At one point, I thought about putting one [ICP] per 100 beds and being done with it."

Jackson said latter phases of the APIC project might derive a specific ratio through collaborative work with the CDC. "Until then, I’m going to stick to one [ICP] per 100 staff beds as my rule of thumb, with no data whatsoever," Scheckler said.

Still, even lowering the ratio to ostensibly increase infection control staff may not be as straightforward a solution as it appears, said Carol O’Boyle, RN, MS, PhD, another principal researcher in the APIC project and supervisor of infection control at the Minnesota Department of Health in Minneapolis. One problem is that ICPs are taking on duties outside their core field of epidemiology, she explained. "There are so many additional tasks that have been put on the ICP, what one does one per 100 [beds] mean?," she told conference attendees. "If the ICP also assumes primary responsibility for a number of functions in the institution, the infection control program is still [understaffed]."

An excellent time to go to administration

But, in addition to patient safety issues, shifting economic trends favor bolstering infection control resources, said Steven Miller, MD, vice president and chief medial officer at Barnes-Jewish Hospital in St. Louis. In an APIC presentation that gave an administrator’s view of infection control, Miller said under old fee-for-service health plans, hospitals could actually be reimbursed for the additional costs of a nosocomial infection. For example, a patient who develops a surgical site infection after cardiac bypass surgery may increase costs by $22,000, he noted. "And this is the argument most of you all have been making for the last several years as to why you should have an infection control program: to avoid these additional costs," Miller said. "But remember, to your hospital administrator, those are actually reimbursable charges."

However, the shift from traditional fee-for-service to capitation and managed care systems has made it less likely that nosocomial infection costs will be reimbursed, a fact that has not been lost on administrators, he noted. "The economic forces have shifted to the point where more and more of our patients are under capitation," he told APIC attendees. "Infections cost us a lot of money."

Couple that trend with the political clout of the patient safety movement, and suddenly expenditures on infection control resources look like a good investment. "You are approaching a really outstanding opportunity at this point in time to improve things for your infection control programs," Miller said. "The Institute of Medicine’s [emphasis] on quality of health care and errors in health care is going to focus some wide attention on what you do. So this is actually going to be an excellent time for you to approach your administration."

References

1. Haley RW, Culver DH, White J, et al. The efficacy of infection surveillance and control programs in preventing outbreaks of nosocomial infections in U.S. hospitals. Am J Epidemiol 1985; 121:182-205.

2. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Infect Control Hosp Epidemiol 1998; 19:114-126.