Control infections through finding trends, problems
Control infections through finding trends, problems
Kansas agency proves it has good infection control
As home health care approaches the 21st century, there is a disturbing trend of antibiotic-resistant bacteria spreading through hospital settings that makes it especially important that quality managers focus on preventing and controlling infections.
By now, most home care nurses have heard of the more common drug-resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). MRSA is a major problem in nearly all major medical centers, and VRE infections have increased rapidly in the 1990s, climbing twentyfold in the first few years of the decade. Also, penicillin-resistant S. pneumoniae, which accounted for 6.6% of total S. pneumoniae strains in the United States in 1992, now accounts for more than 40% of the total strains. Naturally, this problem has spread from hospitals to the communities, and ultimately to the home.
This is why some home care agencies are making infection control projects a top quality improvement priority in recent years.
For example, Susan B. Allen Memorial Hospital Home Health in El Dorado, KS, decided to track every infection treated or noticed among the agency’s patients, beginning in January 1998.
"We were looking to see if we committed any cross-contaminations or certain trends of infections in one type of patient or coming from one type of facility," says Martha McCabe, administrator of the home health department for the hospital-based agency that serves two counties in south-central Kansas, near Wichita.
"We identified two trends in our infection data," she adds. "The majority of our staph or MRSA infections were coming directly out of the hospital into the home, and we narrowed these down to two particular hospitals."
One hospital accounted for all of the MRSA infections. These patients were still on antibiotic treatment when the home care agency admitted them.
"By the time we discharged all of these patients, their cultures and tests were coming back as negative," she adds.
Ruling out trends
The second trend McCabe noticed was that the majority of urinary tract infection (UTI) cases involved patients who had catheters, sometimes for more than a year. These patients often were the multiple sclerosis patients, who were chair-bound or bed-bound, and always were on a round of antibiotics. "Their UTIs always were recurring, and that is something we found not to be uncommon with those patients," she says.
Finally, the agency’s thorough data-collection process helped managers rule out another potential trend: The agency had no instances of cross-contamination while caring for patients.
"We found out that for infections, our outcomes were good," McCabe says.
Here’s a snapshot look at how the agency conducted the quality improvement data collection project:
• The agency maintains a log book for infections. Nurses made entries after obtaining patients’ culture results or when a patient began taking an antibiotic. The entries included the date, type of infection, patient’s identification, and antibiotic prescribed.
"We’d go back on a monthly basis and review all the newly entered infections to see if they were resolved in 30 days, and whether they were kept track of when resolved, and when they occurred," McCabe explains.
• McCabe conducts a sample chart review each month. She assesses whether nurses have entered the required infection information on the patient’s chart. This includes the antibiotic prescribed; onset of infection; category, such as upper respiratory or UTI; the treatment; medication order’s starting date; lab results, and discharge date.
"I look to see if the information has been entered in the infection category, and I also look at the lab results and medication list," she says.
• Nurses are responsible for continually following up on cases and leaving no blank spaces in the logs and charts.
For example, the agency had a case of a draining wound. The nurse called the physician and requested that a culture be conducted, McCabe says. The nurse logged in the infection, but left the box for medication blank because the antibiotic hadn’t been ordered. The log is considered incomplete until the nurse returns to fill in the name of the antibiotic, McCabe says.
So far, the nurses have been doing a very good job keeping track of ongoing cases of infection, she adds.
• Nurses no longer have to write down entries on the log book, once the agency had the resources to start an electronic log. The agency uses a software program that enables nurses to enter infection information while still in the home. The software, created by Patient Care Technologies of Atlanta, is installed in nurses’ portable computers.
The software makes it easy for nurses to update the record anytime during the care process. "Nurses can chart multiple infections and infection sites on the computer," McCabe says. "Then, every month, I go into a menu that is available through this system, and have it compile all the infections for a given period of time."
The software will compile the infections in any way that McCabe desires. For instance, she might desire to see all the infections that occurred on a particular site or of a particular type.
Also, McCabe can assign risk levels to patients by pulling information on nutritional status, infection history, and safety issues.
"The system allows you to draw a list of people who have certain risk factors," she notes. "It allows us to pull a list of people who are at a high risk and make sure they are evaluated."
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