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Agencies that have signed on to the Missouri Alliance for Home Care’s (MAHC) Infection Surveillance Project say it has helped them learn more about infections within their agencies — which ones are causing the most problems and what might be the source of some of them.
Even those agencies that already had successful infection surveillance in place say the benchmarking provided by the nationwide data collection gives them a much better idea of how their agencies are doing.
"I think most of us — those who have been in the project for a while and even the new participants — think it’s benefited their agencies," says Carolyn Crumley, RN, MSN, CS, CWOCN, a clinical nurse specialist at John Knox Village Home Health Agency in Lee’s Summit, MO. "While they’ve been providing data for this overall project, within their individual agency it’s been a benefit to them."
Crumley, who has been associated with the infection surveillance project since 1995, now serves as a trainer for new, out-of-state agencies that join. She leads project managers in new agencies through the minutiae of collecting and reporting data, and reviews their work to make sure it’s consistent with the data being collected by other agencies.
Project manager does most work
Crumley says a participating agency must assign a project manager, who usually does the bulk of the data collection.
"We started out in our agency relying on nur-ses to do more of the data collection, she says. "Through the years, that has changed somewhat to where I try to only ask of the nurses what I have to ask of them, and I try to do the rest."
"I think with PPS [prospective payment system], staffing changes, and other things put on the field nurses, I think it’s pretty similar at most agencies. The project coordinator tries to do as much of the paperwork and chart reviews and all that, just relying on the nurses for the information [he or she] needs to get from them."
At John Knox, the nurses need only tell Crumley which of their patients have bladder or central venous catheters. She does the rest, using chart reviews, physicians’ orders, and lab reports to determine whether a patient meets the definition MAHC has established for a home care catheter infection.
She says it’s "definitely more" work than the agency employed to track infections before she became associated with the MAHC project.
"At that time we didn’t have anybody doing any type of infection surveillance within the agency, as I think was pretty common in most agencies at that point."
By contrast, the United Visiting Nurse Associa-tion in Trumbull, CT, which joined the project three years later, already had begun conducting infection surveillance and had even joined in a smaller attempt at a similar benchmarking project with a handful of New York agencies.
But Susan Brunoli-Stiller, director of quality management, says she never was able to get the kind of useful benchmarking information she was looking for until she joined the Missouri project.
The definitions used were similar to the ones her agency already had been using, so the infection rates reported by her agency were pretty similar to what it had been seeing previously, she says.
Initial rates sometimes high
Crumley and Anne Dillon, MAHC’s projects manager for the Infection Surveillance Project, say that’s not always the case.
Often, Crumley says, new participating agencies may not have been tracking infections as carefully before, and the immediate spike in infection reports may startle or even depress them.
Dillon says when an agency sees itself compared to others in the project, it may have the worst score of the group at first.
"I tell them, Don’t look at this as though you had the worst infection rate ever,"’ she says. "Look at it like there were 41 zeros (meaning no infections) ahead of you, and your infection rate is 1.26. That’s not bad.’
"Our longtime members will be the first ones to tell you they use these data as an active surveillance process," Dillon says. "They follow it from quarter to quarter, looking to see if their infection rate is higher than they would like; and if so, why it is higher?"
Improve one thing at a time
Most of the time, she says, one quarter’s high rate may be because of variables the agency can’t control — a chronic patient, for example. But in other cases, an agency may be able to link an increase to one factor that can be corrected.
Dillon gives the example of a project participant that linked a series of catheter infections to one physician who had inserted the catheters himself.
"They went back to the physician, tactfully saying, This is what we think; and this is the information we’re using to support our theory,’" Dillon says. "The physician actually relinquished that task to one of his nurses, and their infection rate went down."
Brunoli-Stiller says when her agency found itself a bit above the benchmark for urinary tract infections, it focused on those cases to see what was wrong.
"Out of that group of who had [Foley catheters], we isolated that group that developed infections and what was different about them," she says. "We found a couple of things. One was a higher rate of bowel incontinence. We also saw a difference with the type of catheter — people with the latex catheter had higher infection rates."
To address these issues, United Visiting Nurse Association switched to silicone catheters and developed a teaching booklet to educate patients regarding infection control measures.
The number of infections that agencies in the surveillance project can track soon may grow. MAHC soon hopes to be able to field-test a range of new home care definitions drafted by the Wash-ington, DC-based Association for Professionals in Infection Control and Epidemiology.
Those definitions cover everything from respiratory infections such as the common cold and pneumonia to gastrointestinal infections.
MAHC hopes to receive grant funding to help address the expected increase in the cost of tracking the wider array of infections.
For her part, Brunoli-Stiller says she hopes the project will be able to start using the new definitions.
"One of the other definitions would be for wound infection, which we’re very interested in and for which we don’t have a definition, and for pneumonia," she says. She also encourages other agencies to become involved in the project.
• Carolyn Crumley, John Knox Village Home Health Agency, 400 N.W. Murray Road, Lee’s Summit, MO 64081. Phone: (816) 524-1133, Fax: (816) 524-9177. E-mail: firstname.lastname@example.org.
• Anne M. Dillon, Missouri Alliance for Home Care, 2420 Hyde Park Road, Suite A, Jefferson City, MO 65109-4731. Phone: (573) 634-7772. Fax: (573) 634-4374. E-mail: email@example.com.
• Susan Brunoli-Stiller, United Visiting Nurse Associa-tion, 40 Lindeman Drive, Trumbull, CT 06611. Phone: (203) 330-9198. Fax: (203) 396-0506. E-mail: firstname.lastname@example.org.
• For more information on the Missouri Alliance for Home Care’s infection surveillance project, contact the alliance at 2420 Hyde Park, Suite A, Jefferson City, MO 65109-4731. Phone: (573) 634-7772; fax at (573) 634-4374. Web: www.homecaremissouri.org.
• The Association for Professionals in Infection Control and Epidemiology published its draft infection definitions in the December issue of the American Journal of Infection Control. It also has made those definitions available in the resources section of its Web site: www.apic.org/resc/.