Feasibility of National Surveillance of Health-Care-Associated Infections in Home-Care Settings

Lilia P. Manangan, Michele L. Pearson, Jerome I. Tokars, Elaine Miller, William R. Jarvis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Disclosures

Emerging Infectious Diseases. 2002;8(3) 

In This Article

Loss of Patient Follow-up

Home-care patients often are served by several agencies or are readmitted to the hospital during their illness. Lack of continuity of care hampers detection and reporting of health-care-associated infections. For example, if a home-care patient receiving intravenous therapy has a fever, is admitted to an acute-care facility, and is confirmed to have a BSI, this information may not be communicated to the home-care agency (the same or a different one) when the patient is discharged to continue infusion therapy at home.

Surveillance requires adequately trained infection control personnel, but few home health companies have such employees who are designated to conduct infection control activities, including education, surveillance, and prevention. In a recent survey of home-care agencies in Missouri, only 51 (54%) of 95 had a designated infection control practitioner, and only 27 (53%) of 51 provided ongoing training[21]. In most home-care agencies, infection control activities are performed on a volunteer basis with no additional compensation. Successful implementation of surveillance programs and other infection control activities in the home health-care setting will require designated and appropriately trained personnel. Training should include calculation of infection rates, recognition of outbreaks and clusters, providing feedback data to essential personnel, and monitoring compliance of prevention efforts. Educational activities targeted at patients, health-care workers, and other caregivers will also be a necessary part of the infection control program.

Many home-care agencies are privately owned and have no hospital or laboratory affiliation; therefore, access to diagnostic services may be limited, and home-care personnel may have difficulties in tracking laboratory results (e.g., contacting out-of-state physician offices or laboratories). Limited access to test results may also encourage home-care personnel to use empiric therapy without documentation of infection or identification of a causative pathogen. Linkages for sharing clinical and laboratory data among physicians, hospitals, and home-care agencies are essential to optimize patient care in the home.

Surveillance for infections in home care will require methods to identify appropriate numerator and denominator data for calculating infection rates for inter- and intra-agency comparison and benchmarks. Collection of numerator data (e.g., BSI or other infectious complications) will require systems that permit data sharing by hospitals and laboratories with home-health agencies.

Capturing appropriate denominator data may even be more difficult[22]. For example, to determine device-associated infection rates, device utilization must be measured by monitoring days of use. However, if insertion, care, and removal of the device (e.g., central venous catheter, urinary catheter, tracheostomy tube) are done in different health-care settings, it will be difficult to monitor how many days a device is used. Although infection rates based on device utilization have been shown to be necessary in the acute-care setting, it is not certain that they are necessary in home care.

Another option for denominator is the number of days a patient uses a device during home care only, rather than the total number of days (i.e., from insertion to removal) the device is used. Because all home infusion therapy patients have intravenous catheters, patient days may be substituted for device days as long as they equal one another.

In addition to these challenges, the home-care industry will have to deal with the financial implications of implementing and maintaining a national surveillance system. Data on the cost of a surveillance system and on methods of calculating that cost into the reimbursement systems of health-care payors are very much needed.

Despite cost concerns, patient safety and outcomes are becoming increasingly important in the current health-care environment. Purchasers should base their selection of a home-care agency on patient outcomes and satisfaction rather than cost. Thus, home care agencies must conduct surveillance for adverse events. Without such surveillance systems, it would be very difficult for agencies to know if problems are occurring and whether quality care is being provided.

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