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The goal? Standard infection definitions
Eight years ago, a few home care nurses began meeting in a spare conference room at the Missouri Alliance for Home Care (MAHC) in Jefferson City. Their goal: to begin a program of tracking infection rates at state agencies.
Today, that effort has spread to 91 agencies across the country that report quarterly on rates of bladder catheter and central venous catheter infections within their organizations. Participating agencies use the nationwide data as a benchmark for their own rates.
The MAHC infection surveillance project also has joined a larger nationwide effort to create infection definitions that apply specifically to home care operations. That effort has led to collaborations with the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC) in Atlanta.
The Missouri project members soon hope to field-test a range of different draft infection definitions created by APIC.
"Everybody has the same goal, which is really to standardize the home care definitions and get them out there for the masses," says Anne Dillon, projects manager for MAHC’s infection surveillance project.
Home care infection experts say standardization is sorely needed. Libby Chinnes, RN, BSN, CIC, a infection control consultant with Mount Pleasant, SC-based IC Solutions, heads up APIC’s home care section.
Chinnes says that in the past, home health nurses have had to use infection definitions written for acute-care settings, which often are unsuited to a home care environment. "The hospital definitions many times call for a lot of specific lab tests, and you may not have that in home health — maybe the wound was not cultured, or maybe a urine culture was not obtained."
A definition written specifically for home care might include not just lab tests as an indicator, but other signs and symptoms that could be used if tests weren’t available.
Carolyn Crumley, RN, MSN, CS, CWOCN, a clinical nurse specialist at John Knox Village Home Health Agency in Lee’s Summit, MO, says hospital definitions don’t take into account the tremendous difference in the home environment. Patients are seen by nurses less frequently, the cleanliness standards are different — there sometimes are even different types of bacteria to contend with.
According to Dillon, home care definitions also can help differentiate between infections acquired in home care and infections the patient acquired in the hospital — an important distinction when an agency is trying to determine if its infection control procedures are optimal.
Over the years, many agencies have cobbled together their own working definitions of home care infections for use by their own staff. But Chinnes says those definitions vary from agency to agency. The goal of the APIC effort is to offer a standardized set of written definitions across the home care discipline.
Years of work pay off
The standardization process hasn’t been easy. Chinnes says the APIC home care section worked on its set of definitions for more than three years.
The MAHC group spent two to three years refining only two definitions — one for central venous catheter infections and one for bladder catheter infections.
"I think they were interested in learning about other types of infections," Dillon says. "But as the project progressed, and they got into nitty-gritty of developing definitions, they thought that the bladder catheter and central venous catheter definitions were more manageable."
For the first few years, the group of volunteer nurses would meet, hammer out a definition, then return to their agencies to field-test it. They’d come back, share their opinions about what worked and what didn’t, refine the definition, and go home to try it out again.
Crumley, who joined the MAHC project in 1995, says the refinements came not only from the agencies’ experiences, but also from what little literature was starting to appear on home care infection surveillance.
"It was right about that same time we started seeing more articles that pointed us toward specific definitions and criteria that some of the agencies were starting to collect data."
Dillon says it wasn’t until 1996, when she first was hired, that the nurses had fine-tuned the two catheter definitions to the point that they could use them for an entire year before tweaking them again. Crumley says the definitions have changed very little since then.
As word spread about the project, more Missouri agencies asked to be included. The effort also spread across state lines, as nurses heard about the infection surveillance project at conferences.
Dillon says MAHC has always been open to extending the reach of the project, believing that every agency that participates brings valuable data that the others can use. The project now includes 91 agencies in 22 states, including Michigan, whose state home care association has a formal relationship with MAHC that allows 23 Michigan agencies to participate at a reduced price.
The project is free to MAHC members. Members in other states (excluding Michigan) pay $300 for the first year of participation in the project, and $200 each subsequent year.
Dillon says MAHC only charges what is necessary to run the project.
"The first year, it was $100 per company and that was not helping at all with expenses," she says. "We changed it so that it would be $300 for the first year, which is the most labor-intensive year as far as the staff here. After that, it’s only $200."
Collecting the data
When an agency signs up, it is assigned a trainer who reviews the agency’s plan for collecting and reporting the necessary infection data. The goal is to make sure the plan is comparable to what other agencies in the project are doing, Dillon says.
"They can collect the data however they would like — based on their own internal system — as long as they’re counting days correctly, counting patients correctly, and meeting the criteria of the definition."
MAHC provides quarterly reports to participants, breaking out the data so that an agency can measure itself against other similar agencies.
"We have every participating company fill out a demographics sheet," Dillon says. "And we use those elements to put them into categories. The reports show breakouts based on whether they’re urban or rural, hospital-based or freestanding, and the size of their agency."
Agencies that receive an information packet on the project and decide not to join still are allowed to use the definitions and data collection recommendations for their own personal surveillance, but won’t have access to the benchmarking information, Dillon says.
Jeanne Schrader, RNC, BS, clinical care coordinator at Memorial Hospital Home Care in Belleville, IL, says when she first looked into the infection surveillance project, her agency couldn’t afford the fee. So they used the definitions and created their own smaller benchmarking group with other Illinois agencies.
That group, which began three years ago with 12 members, has since dwindled to seven. But Schrader says they, too, have benefited from the opportunity to compare their rates against each other and against rates they’ve found while reviewing medical literature.
"I think MAHC did a really good job with setting up the program, and I couldn’t see any reason to reinvent the wheel," she says.
More definitions to become available
With its infection surveillance program in place, MAHC established a relationship with APIC several years ago to join in the association’s efforts to standardize infection definitions in home health.
Chinnes credits MAHC and particularly its executive editor, Mary Schantz, with providing valuable feedback on APIC’s draft definitions.
MAHC and APIC also collaborated on the first national infection control conference addressing home care issues in October 1999, and on a second conference last year. Dillon says a third conference is tentatively scheduled for Oct. 11-12 in St. Louis.
Also involved in the effort is the CDC, which has conducted period prevalence studies among Missouri agencies. The goal of the studies is to determine the number and types of home care infections during different one-month periods. Information from the surveys was made available at the 1999 home care infection surveillance conference.
"They’ve been absolutely wonderful," Chinnes says of the CDC. "They have a lot of interest in home care, and they’re trying to help us as struggling practitioners in the field to get in there and make this work."
The next step is to field-test APIC’s definitions, which include such areas as wound infections, respiratory infections, and gastrointestinal infections. The definitions, which were approved by the APIC board, were published in the December issue of the American Journal of Infection Control. They also are available on the association’s Web site at www.apic.org.
Dillon says MAHC is anxious to begin working the APIC definitions, but will need more money to administer the project. The alliance has applied for a grant to cover the increased costs.
Crumley says that while gathering data on the new set of definitions will require more work, it definitely will be worth the effort. She says one result of all of the nationwide efforts at standardizing home care infection surveillance has been an increased awareness of the issue throughout the home health industry.
"I think in the whole home health setting, we’re more aware of infections than we ever were before," Crumley says. "We’re more aware of our role in infection surveillance, and more agencies are actually doing infection surveillance."
• Libby Chinnes, IC Solutions, 524 Crowfield Lane, Mount Pleasant, SC 29464. Telephone: (843) 849-6027. Fax: (843) 881-3714. E-mail: firstname.lastname@example.org.
• 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: email@example.com.
• 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: firstname.lastname@example.org.
• Jeanne Schrader, RNC, BS, Memorial Hospital Home Care, 4500 Memorial Drive, Belleville, IL 62226. Phone: (618) 257-5700. Fax: (618) 257-6949.