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

Progress Toward a National Surveillance System for Health-Care-Associated Infections

Several groups are collecting data on health-care-associated infections in home care and other outpatient areas. These data may prove useful in developing a national home health-care surveillance system.

MAHC is a nonprofit association that provides home care education, advocacy, and information for its 250-member agencies, most of which are located in Missouri. In the early 1990s, MAHC established an infection control committee composed of nurses who provided infection control activities for their agencies. In 1993, the committee implemented the MAHC Infection Surveillance Project (ISP) to monitor infections associated with central venous and urinary catheters. ISP is an active surveillance system that uses standardized criteria and definitions for tracking, aggregating, and reporting urinary infections and BSIs among home-care patients. Currently, 99 home-care agencies from 25 states participate in ISP. Although MAHC has contracted with the Hospital Industry Data Institute, Missouri Hospital Association, to organize and present the ISP data, the results have not yet been published. Although the ISP definitions have not been validated to determine sensitivity and specificity, the data allow participating agencies to compare their infection rates with those of other agencies.

On a broader scale, the Health Care Financing Administration (HCFA), now the Center for Medicre and Medicaid Services, in collaboration with the Center for Health Sciences and Policy Research, has developed the Outcome and Assessment Information Set (OASIS) to measure patient outcomes and improve quality in home care. HCFA requires all Medicare-certified home-care agencies to electronically submit data for their Medicare patients to a central OASIS database in Baltimore, Maryland. The outcomes monitored in OASIS are changes in patient health status, as indicated by need for emergency care or hospitalization, for example. Data collected include patient demographics and medical history, living arrangements, type of wound, urinary tract infection, respiratory devices, medications, emergency care received, transfer to an inpatient facility, and death. Most data items are obtained at start of care, every two calendar months, and at discharge. Since August 1999, more than eight million records have been entered into the OASIS database, and information on how to access the OASIS reports can be obtained from http:/.www.hcfa.gov/medicaid/oasis/osishmp.htm.

Another national and international data source is the Outpatient Parenteral Antimicrobial Therapy (OPAT) registry, which aims to improve delivery of care and outcomes for outpatients receiving parenteral antimicrobial therapy. OPAT provides a broad database for assessing antimicrobial drug-prescribing practices and outcomes among patients with infections treated in outpatient settings. Data collected include patient demographics, diagnosis, pathogen, venous access device, infusion system, adverse events, clinical outcome, and patient satisfaction. Currently, 25 OPAT provider sites from 16 states are participating in the U.S. registry, and 24 provider sites from 6 countries are in the international registry. OPAT data have been presented at scientific conferences[23].

Surveillance methods that are commonly used in hospital programs may not be feasible for home care. Different strategies are needed to make surveillance in the home easier to implement, particularly if adequately trained staff and diagnostic services are limited. For example, the Dialysis Surveillance Network provides a novel way of tracking hospitalization, antimicrobial use, and selected infections in hemodialysis outpatients[24]. Episodes of potential infection are identified by a clearly defined sequence of steps that involves completing an "incident form" for all patients admitted to a hospital or started on intravenous antimicrobial therapy. The presence (or absence) of symptoms indicating infection is recorded rather than the infections themselves, and a computer algorithm determines whether the infection case definitions are met; the data collector is not required to memorize case definitions. The lessons from this surveillance system, in addition to other traditional outpatient systems, may be useful in establishing national surveillance for home health-care-associated infections.

Nearly as many patients receive home care annually as hospital care. With the continued expansion of home health-care delivery and documented infection risk in this setting, a national system for surveillance of health-care-associated infections in the home-care setting is needed. Collaboration between home health-care agencies, state and federal health agencies, private industry, and national or managed-care organizations is essential to make this system feasible and functional. Development and implementation of such a system would foster better understanding of the epidemiology of health-care-associated infections in the home-care setting. Furthermore, this system would provide a means for monitoring the impact of interventions aimed at preventing the emergence of these infections in the home.

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