- Email: [email protected]
Infection control program disparities between acute and long-term care facilities in Maryland
Infection control program disparities between acute and long-term care facilities in Maryland Brenda J. Roup, PhD, RN, CIC,a Jeffrey C. Roche, MD, MPH,a and Margaret Pass, RN, BSN, MS, CICb Baltimore, Maryland
Background: In January 2003, the Maryland State Department of Health and Mental Hygiene (DHMH) surveyed, for the first time, all acute care hospitals (ACHs), long-term care facilities (LTCFs), and specialty hospital (acute rehabilitation and behavioral health) facilities in the state to determine the current state of infection control resources and practices in Maryland. Federal health care facilities in Maryland were not surveyed. Methods: A self-administered questionnaire was sent to all 40 ACHs, 247 LTCFs, and 20 specialty hospitals in the state. The senior infection control professional (ICP) in the facility completed the questionnaire. Results: The response rates were 85% for ACHs, 39% for LTCFs, and 95% for specialty hospitals. Data were analyzed separately for each type of facility. The ICPs in acute care reported 1.2 full-time equivalent positions (FTEs) for each 200 acute care beds, whereas ICPs in LTCFs reported 0.3 FTEs per 200 LTCF beds. Ninety percent of acute care ICPs reported taking some type of basic infection control course, whereas only 3% of long-term care ICPs reported taking a basic infection control course. Conclusion: In this survey of ICPs in Maryland, striking differences were noted between ACHs and LTCFs in the ratio of ICP FTEs to beds and in basic infection control educational preparation for ICPs. These findings suggest that Maryland LTCFs could benefit from basic infection control training and from regulatory actions addressing staff-to-resident ratios. (Am J Infect Control 2006;34:122-7.)
Under Maryland law, the Department of Health and Mental Hygiene (DHMH) is responsible for promoting the health of all Maryland citizens. The DHMH Community Health Administration’s Office of Epidemiology and Disease Control Programs (EDCP) receives hundreds of requests from health care facilities per year for assistance related to prevention and control of infection. These requests come from acute care hospitals (ACHs), long-term care facilities (LTCFs), and specialty hospitals in the State. EDCP staff have noticed that although infection control professionals (ICPs) in acute and specialty hospitals are usually knowledgeable about and have had training in infection prevention and control, ICPs from long-term care facilities did not seem to have the same degree of knowledge and training. These observations concur with the findings of an earlier survey of infection control (IC) resources and
From the Maryland Department of Health and Mental Hygiene,a Office of Epidemiology and Disease Control Programs, Baltimore, MD, and Johns Hopkins Hospital,b Department of Hospital Epidemiology and Infection Control, Baltimore, MD. Reprint requests: Brenda J. Roup, PhD, RN, CIC, Maryland Department of Health and Mental Hygiene, 201 West Preston Street, Baltimore, MD 21201. E-mail: [email protected]. 0196-6553/$32.00 Copyright ª 2006 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2005.12.010
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practices in Maryland. In this 1988 survey, Khabbaz and Tenney noted that the designated ICPs in 53 randomly chosen Maryland LTCFs had multiple roles within the facility and often lacked IC–related training.1 A Medline search of the published literature relating to IC resources and practices from 1990 to 2004 yields primarily prescriptive articles, ie, discussions and recommendations for IC staffing and other resources or infrastructure concerns.2-3 Maryland’s population is served by a combination of health care facilities of different types. As of July 1, 2003, Maryland had an estimated population of 5,508,909. Persons over the age of 65 comprise approximately 11% of the population, a proportion that has not changed substantially from 1990 to the present.4 In addition, people from states outside Maryland and from many other countries seek care in several universityaffiliated tertiary care and research hospitals here. Maryland’s health care facilities provide services across the spectrum of care and are composed of 40 ACHs (15 with 200 or fewer beds, and 25 ACHs with more than 200 beds), 247 LTCFs, and 20 specialty hospitals. Specialty hospitals include acute rehabilitation and behavioral health facilities. In aggregate, these 307 facilities support 13,741 licensed acute and specialty hospital beds and 29,137 licensed long-term care beds.5 To determine current IC resources and practices and the potential for additional assistance that DHMH might provide, a survey of all nonfederal ACHs, LTCFs, and specialty hospitals in the state was conducted.
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Table 1. Survey response rates before and after reminder postcard
Responses after initial mailing Increase in responses after postcard reminder Total responses
Acute, #200 beds
Acute, .200 beds
Long-term care facility
Specialty
Total
12/15 (80) 3/15 (20) 15/15 (100)
15/25 (60) 6/25 (24) 21/25 (84)
72/247 (29) 24/247 (10) 96/247 (39)
11/20 (55) 8/20 (40) 19/20 (95)
110/307 (36) 41/307 (13) 151/307 (49)
Data given as n (%).
METHODS This project was submitted to the Maryland DHMH Institutional Review Board in July 2002 and received approval as exempt research in August 2002. A survey instrument entitled ‘‘Survey of Maryland Infection Control Resources and Practices’’ was developed by DHMH and was based, in part, on a similar survey instrument used by the New York State Department of Health and Mental Hygiene in 1999.6 Participation of all inpatient facilities in Maryland was solicited. Because the numbers of facilities in the state are not large, it was thought that surveying the entire cohort of facilities would yield a more accurate picture of IC resources and practices. It was estimated that the time and resources needed to survey the entire population of facilities were not significantly greater than that needed to survey a sample. Using simple descriptive survey methodology, a wide range of IC resources and practices in Maryland was assessed. The senior ICPs in the facilities completed the survey during January 2003. The unit of analysis in this survey was the individual facility, regardless of the number of ICPs employed in that facility. Each facility was mailed one survey. The survey was intended to solicit the scope of responsibilities, the amount and types of support, and the range of certain IC practices among Maryland health care facilities, and included quantitative and qualitative components. The survey solicited information about the following: (1) basic facility characteristics and functions; (2) IC and health care epidemiology personnel; (3) IC organization within the facility; (4) committee service; (5) coverage responsibility of ICPs, ie, numbers of beds, ambulatory clinics, dialysis centers, etc; (6) support services available to ICPs; (7) types of surveillance activities and outbreak reporting procedures; (8) isolation capacity; (9) involvement in employee health programs; (10) emergency preparedness related to IC; and (11) education and training of ICPs. Half of the questions required discrete answers, ie, yes, no, or I don’t know, and the remaining half required narrative answers. The survey was pretested by two experienced ICPs from ACHs and two ICPs from LTCFs. This pretest assessed the survey instrument for clarity and content validity. The four ICPs rated the questions as clear and unambiguous; therefore, no changes were made in the
original wording of the questions. The content validity was assessed by having the ICPs match the survey questions with the objectives of the project, thus determining whether or not the information required was actually being solicited. The content validity index was 0.8, thus indicating that the survey measured what it proposed to measure, ie, the IC resources and practices present in several categories of Maryland health care facilities in 2003.7 Internal consistency reliability of the survey was greater than 0.70, indicating satisfactory reliability.8 The survey instrument was mailed to each ACH, LTCF, and specialty hospital in Maryland in January 2003. Each survey was accompanied by an explanatory letter that requested that the senior ICP of the facility complete the survey and return it by fax or in the enclosed self-addressed, stamped envelope. This first mailing of 307 surveys was completed by January 30, 2003. Three weeks after the initial mailing, a followup postcard was mailed to the 197 facilities that had not responded. The postcard reminders prompted 41 requests for a new survey, the initial one having been lost or mislaid. These were mailed by March 15, 2003. Data from responding facilities were entered into a spreadsheet program for descriptive statistics that included linear regression calculations. Data were analyzed separately for each type of facility, ie, ACHs with 200 or fewer beds, ACHs with more than 200 beds, LTCFs, and specialty hospitals. The x2 statistic for statistical significance was calculated with the Bonferroni correction for multiple comparisons.9
RESULTS Table 1 outlines response rates by type of facility. Three weeks after the initial mailing of surveys, and before the reminder postcards were sent, the initial overall response rate was 36%. The final overall response rate was 49% for all facilities surveyed. Of note, reminder postcards increased the overall response rate by 13%. Several important differences emerged after analysis of the responses. These differences included staffing patterns, training of ICPs, and the number and scope of non-ICP responsibilities. First, facilities differed markedly in their ICP staffing. Mean ICP staffing in ACHs with 200 or fewer beds was 1.6 full-time
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Fig 1. Acute hospital infection control professional full-time equivalent staff by beds.
Fig 2. Long-term care facility infection control professional full-time equivalent staff by beds. equivalent (FTE) positions per facility (range, 1 to 2 FTEs). ACHs of more than 200 beds reported a mean of 2.0 FTEs per facility (range, 1 to 6 FTEs). The correlation of ICP FTE staffing and bed size at ACHs is shown in Figure 1. Generally, ACH ICP staffing is strongly positively correlated with numbers of acute beds (Pearson correlation coefficient, r 5 0.92, P , .001). In a reanalysis of only those ACHs with fewer than 500 beds (to eliminate the outlier effects of Maryland’s largest and second largest ACHs), correlation of ICP FTE staffing with bed size remains highly positive (Pearson correlation coefficient, r 5 .75, P , .001). In marked contrast with ACHs, Figure 2 shows that there seems to be no significant correlation between the numbers of ICP FTEs at LTCFs and facility beds (Pearson correlation coefficient, r 5 0.17, P , .10). Of the 50% of responding LTCFs who answered that
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Fig 3. Organizational placement of infection control.
survey question, the mean number of ICP staff was 0.3 FTEs (range, 0.1 to 2.5 FTEs) for facilities ranging in size from 25 to 550 beds. Finally, the 13 specialty hospitals responding to this question reported mean ICP FTE staffing of 1.1 FTEs (range, 0.1 to 3 FTEs) for facilities covering a total of 41 to 412 acute and chronic licensed beds. There was only a moderate correlation between the numbers of beds in these facilities and ICP staffing (Pearson correlation coefficient, r 5 0.48, P , .2). Figure 3 shows the reporting relationships of IC programs within their facilities. A majority of ACHs of all sizes place ICPs organizationally under quality improvement programs. In contrast, ICPs in responding LTCFs and specialty hospitals have IC programs that report to nursing management. The survey also found differences in how frequently ICPs at different types of facilities are assigned to perform non-IC duties. When asked about assignment of non-IC duties to ICPs, 73% of ACHs with 200 or fewer beds answered yes and 24% of ACHs with more than 200 beds answered yes; for LTCFs, 95% answered yes; and for specialty hospitals, 79% answered yes. Overall, 89% of LTCFs, specialty hospitals, and ACHs with 200 or fewer beds assign their ICPs additional duties or non-IC functions. When asked to specify the nature of these other assigned duties, ICPs listed 31 other functions they were required to perform. In all ACHs and specialty hospitals, the predominant non-IC responsibility was for employee health activities. In LTCFs, the three most commonly reported non-IC functions were employee health, staff development, and quality improvement activities. In this State, it would not be unusual for a full-time RN in an LTCF to be expected to perform IC, employee health, staff development, and quality
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improvement activities, with only 10% to 20% of that position allotted for IC activities. Figure 4 shows the relative frequency of the eight most frequently reported non-IC responsibilities. In addition to these non-IC duties, ICPs in Maryland frequently have responsibility for IC activities in other facility components that are affiliated with or comprise parts of that health care facility or system. Table 2 lists these responsibilities for the four different types of facilities. For example, the median ICP responsibilities in an ACH with 200 or fewer beds includes 140 acute beds, 10 subacute or long-term care beds attached to the acute facility, 1 ambulatory surgery center, 1 other ambulatory clinic, and at least 1 physician’s office. For an ACH with more than 200 beds, these responsibilities increase to 292 acute beds, 15 long-term care beds, 1 drug treatment center, at least 1 large ambulatory surgical center, and at least 1 physician’s office. These IC duties are expected to be performed in addition to any non-IC duties that are assigned to the ICP. The survey also requested information about ICP participation in non-IC committees. Table 3 lists the various facility committees by type of facility in which Maryland ICPs participate. In ACHs, ICPs most often serve on safety, product evaluation, and disaster/ emergency preparedness committees. LTCF ICPs serve most often on quality assurance and safety committees. In specialty hospitals, ICPs serve most often on safety, product evaluation, and pharmacy and therapeutics committees. Survey findings about employee health responsibilities show that Maryland ICPs participate in a wide variety of functions related to disease screening and prevention and to exposure management. The most commonly reported activities in all facilities included placement and monitoring of tuberculosis skin tests, administration and compliance monitoring of hepatitis B and influenza vaccines, and management of postexposure prophylaxis for health care workers after a blood or body fluid exposure. Lastly, the survey solicited information about the basic IC training of ICPs working in health care facilities. All 55 responding ACHs and specialty hospitals (95%) have at least one ICP with basic IC training. In contrast, only 8 (8.0%) of 96 responding LTCFs have at least one ICP with basic IC training, such as that offered by the Association for Professionals in Infection Control and Epidemiology (APIC).
DISCUSSION Forty-nine percent of ACHs, LTCFs, and specialty hospitals in the state responded to the survey. A limitation of the survey is the lack of detailed information about those facilities who did not respond.
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Fig 4. Relative frequency of other responsibilities of infection control professionals.
For example, although 2 in 5 LTCFs responded to the survey, a preliminary analysis of the LTCF nonresponder group showed no significant differences between responders and nonresponders in relationship to geographic location in the state, the numbers of licensed beds, or whether or not the facility was part of an LTCF chain. Infections in LTCFs and other health care settings are important public health concerns. A review of DHMH data (unpublished) from reported outbreaks in LTCFs during the period of 1999 to 2003 showed that an average of more than 160 outbreaks of infectious diseases in LTCFs were reported each year and involved a total of more than 4,700 cases of illness. The occurrence of this large number of illnesses among such a vulnerable population represents a significant public health challenge. However, these survey results indicate that the individuals who are expected to prevent and manage outbreaks, ie, LTCF ICPs, are the ones with the least amount of IC training and the most demands on their time from non-IC duties. This is an ominous finding because many of today’s residents of LTCFs would have been acute hospitals patients as recently as 10 years ago.10 This increasing challenge of effectively providing the knowledge and skills needed to deal with IC issues in the LTCF setting is recognized at the national level. The Institute of Medicine’s Committee on Quality of Health Care in America reviewed this situation in the executive summary of their 2004 report11: . Like newly licensed physicians, newly licensed nurses need additional training and education once they enter the workforce [.] . experienced
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Table 2. Median coverage responsibilities of infection control professionals by facility type
Acute beds Long-term beds Drug treatment centers Dialysis centers Ambulatory surgery centers Other ambulatory clinics Physician offices Other facilities Mean infection control staff full-time equivalent positions
Acute care, 200 beds or fewer (n = 15)
Acute care, more than 200 beds (n = 21)
Long-term care facility (n = 96)
Specialty hospital (n = 19)
140 (20–200) 10 (0–69) 0 (0–5) 0 (0–15) 1 (0–6) 1 (0–4) 0 (0–1) 0 (0–1) 1.6 (1–2)
292 (233–1025) 15 (0–88) 1 (0–5) 1 (0–8) 1 (0–100) 1 (0–5) 1 (0–7) 2.5 (0–5) 2.0 (1–6)
100 (25–550) 0 (0–1) 0 (0–6) 0 (0–2) 0 (0–3) 0 (0–7) 0 (0–1) 0.3 (0.1–2.5)
97 (7–225) 106 (20–266) 0 (0–65) 0 (0–6) 0 (0–18) 0 (0–20) 0 (0–19) 0 (0–0) 1.1 (0.1–3)
Data given as n (range).
Table 3. Infection control professionals participation in non–infection control committees by facility* Committee involvement
Safety Quality assurance/improvement Disaster/emergency preparedness Product evaluation Pharmacy and therapeutics Construction/renovation planning Risk management Mortality review Prospective payment system
Acute # 200 (n = 15)
Acute . 200 (n = 21)
Long-term care facility (n = 96)
Specialty (n = 19)
Totaly (n = 151)
94 69 100 94 69 71 20 10 0
100 53 95 100 70 80 6 6 0
71 85 54 32 32 17 37 33 24
90 80 80 84 84 53 53 28 12
80 79 68 55 48 36 34 27 18
*Percent answering yes of facilities responding of that facility type. y Including all facility types.
nurses similarly need ongoing education and training to keep up with the continuing growth of new medical knowledge and technology. [H]ospitals are reported to have scaled back orientation programs for newly hired nurses, as well as ongoing in-service training and continuing education programs, as a result of financial pressures. The committee found evidence that all health care professionals (nurses and physicians alike) need better training, as well as organizational practices that promote and support interdisciplinary collaboration and teamwork. Although these comments go beyond the concerns of IC competency in all health care settings, they indicate the close connection between patient safety and effective ICP education. In summary, this survey of IC resources and practices in ACHs, LTCFs, and specialty hospitals in Maryland provides insight about current IC resources and practices in Maryland health care facilities. For example, survey results suggest that LTCFs could benefit from DHMH-approved IC training and from regulatory actions addressing ICP staffing pattern requirements. One immediate response to this need in Maryland
was the establishment in 2004 of a 3-day basic IC course with specific emphasis on IC in a nonhospital facility. Participants included ICPs from more than 86 LTCFs across the state, as well as communicable disease nurses from local health departments and nurse surveyors from the DHMH Office of Health Care Quality. A potential additional DHMH response to these IC program disparities is a new DHMH regulation that will require at least one individual who has basic IC training to be designated as the ICP at each LTCF facility in the state. This new regulation is currently under review by state officials. However, no recommendations have been made thus far concerning ICP-to-residents staffing patterns for LTCFs. These survey results and their implications will be disseminated to all health care facilities in Maryland in the near future, to be followed by the results and conclusions about public health’s need to develop and expand existing relationships with ICPs in health care facilities in Maryland. The authors thank the following for their support of this project: The Greater Baltimore Chapter, The Association for Professionals in Infection Control and Epidemiology (APIC); the ICPs at Maryland health care facilities who completed and returned the survey; Ms. Erika Kalp, MPH, and Ms. Kimberly Jones for data entry; and Ms. Pat Ryan for careful review of the manuscript.
Roup, Roche, and Pass References 1. Khabbaz R, Tenney J. Infection control in Maryland nursing homes. Infect Control Hosp Epidemiol 1988;9:159-62. 2. Morrison J, Health Canada, Nosocomial Occupational Infections Section. Development of a resource model for infection prevention and control programs in acute, long-term, and home care settings. Am J Infect Control 2004;32:2-6. 3. Friedman C, Barnette M, Buck A, Ham R, Harris J, Hoffman P, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings. Infect Control Hosp Epidemiol 1999;20:695-705. 4. Maryland Department of Health and Mental Hygiene, Vital Statistics Administration. Maryland vital statistics 2003 preliminary report. Baltimore, MD; August 2004. 5. Maryland Department of Health and Mental Hygiene, Office of Health Care Quality. Provider listings. Baltimore, MD; August 2004.
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6. Dunham A, Stricof R. Infection Control Resources. New York State Acute Care Facilities, 1999. Proceedings: Centers for Disease Control and Prevention 4th Decennial International Conference on Nosocomial and Health care-Associated Infections. Atlanta, GA; 1999. 7. Waltz C, Jenkins L. Measurement of nursing outcomes. New York: Springer Publishing; 2002. 8. Waltz C, Jenkins L. Measurement of nursing outcomes. New York: Springer Publishing; 2002. 9. Altman D. Practical statistics for medical research. London: Chapman and Hall; 1991. 10. Jarvis W. Infection control and changing health-care delivery systems. Emerg Infect Dis 2001;7:170-3. 11. Board on Health Care Services of the Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Excerpted from executive summary, pp. 1-22. Washington, DC: National Academies Press; 2004.
Background: In January 2003, the Maryland State Department of Health and Mental Hygiene (DHMH) surveyed, for the first time, all acute care hospitals (ACHs), long-term care facilities (LTCFs), and specialty hospital (acute rehabilitation and behavioral health) facilities in the state to determine the current state of infection control resources and practices in Maryland. Federal health care facilities in Maryland were not surveyed. Methods: A self-administered questionnaire was sent to all 40 ACHs, 247 LTCFs, and 20 specialty hospitals in the state. The senior infection control professional (ICP) in the facility completed the questionnaire. Results: The response rates were 85% for ACHs, 39% for LTCFs, and 95% for specialty hospitals. Data were analyzed separately for each type of facility. The ICPs in acute care reported 1.2 full-time equivalent positions (FTEs) for each 200 acute care beds, whereas ICPs in LTCFs reported 0.3 FTEs per 200 LTCF beds. Ninety percent of acute care ICPs reported taking some type of basic infection control course, whereas only 3% of long-term care ICPs reported taking a basic infection control course. Conclusion: In this survey of ICPs in Maryland, striking differences were noted between ACHs and LTCFs in the ratio of ICP FTEs to beds and in basic infection control educational preparation for ICPs. These findings suggest that Maryland LTCFs could benefit from basic infection control training and from regulatory actions addressing staff-to-resident ratios. (Am J Infect Control 2006;34:122-7.)
Under Maryland law, the Department of Health and Mental Hygiene (DHMH) is responsible for promoting the health of all Maryland citizens. The DHMH Community Health Administration’s Office of Epidemiology and Disease Control Programs (EDCP) receives hundreds of requests from health care facilities per year for assistance related to prevention and control of infection. These requests come from acute care hospitals (ACHs), long-term care facilities (LTCFs), and specialty hospitals in the State. EDCP staff have noticed that although infection control professionals (ICPs) in acute and specialty hospitals are usually knowledgeable about and have had training in infection prevention and control, ICPs from long-term care facilities did not seem to have the same degree of knowledge and training. These observations concur with the findings of an earlier survey of infection control (IC) resources and
From the Maryland Department of Health and Mental Hygiene,a Office of Epidemiology and Disease Control Programs, Baltimore, MD, and Johns Hopkins Hospital,b Department of Hospital Epidemiology and Infection Control, Baltimore, MD. Reprint requests: Brenda J. Roup, PhD, RN, CIC, Maryland Department of Health and Mental Hygiene, 201 West Preston Street, Baltimore, MD 21201. E-mail: [email protected]. 0196-6553/$32.00 Copyright ª 2006 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2005.12.010
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practices in Maryland. In this 1988 survey, Khabbaz and Tenney noted that the designated ICPs in 53 randomly chosen Maryland LTCFs had multiple roles within the facility and often lacked IC–related training.1 A Medline search of the published literature relating to IC resources and practices from 1990 to 2004 yields primarily prescriptive articles, ie, discussions and recommendations for IC staffing and other resources or infrastructure concerns.2-3 Maryland’s population is served by a combination of health care facilities of different types. As of July 1, 2003, Maryland had an estimated population of 5,508,909. Persons over the age of 65 comprise approximately 11% of the population, a proportion that has not changed substantially from 1990 to the present.4 In addition, people from states outside Maryland and from many other countries seek care in several universityaffiliated tertiary care and research hospitals here. Maryland’s health care facilities provide services across the spectrum of care and are composed of 40 ACHs (15 with 200 or fewer beds, and 25 ACHs with more than 200 beds), 247 LTCFs, and 20 specialty hospitals. Specialty hospitals include acute rehabilitation and behavioral health facilities. In aggregate, these 307 facilities support 13,741 licensed acute and specialty hospital beds and 29,137 licensed long-term care beds.5 To determine current IC resources and practices and the potential for additional assistance that DHMH might provide, a survey of all nonfederal ACHs, LTCFs, and specialty hospitals in the state was conducted.
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Table 1. Survey response rates before and after reminder postcard
Responses after initial mailing Increase in responses after postcard reminder Total responses
Acute, #200 beds
Acute, .200 beds
Long-term care facility
Specialty
Total
12/15 (80) 3/15 (20) 15/15 (100)
15/25 (60) 6/25 (24) 21/25 (84)
72/247 (29) 24/247 (10) 96/247 (39)
11/20 (55) 8/20 (40) 19/20 (95)
110/307 (36) 41/307 (13) 151/307 (49)
Data given as n (%).
METHODS This project was submitted to the Maryland DHMH Institutional Review Board in July 2002 and received approval as exempt research in August 2002. A survey instrument entitled ‘‘Survey of Maryland Infection Control Resources and Practices’’ was developed by DHMH and was based, in part, on a similar survey instrument used by the New York State Department of Health and Mental Hygiene in 1999.6 Participation of all inpatient facilities in Maryland was solicited. Because the numbers of facilities in the state are not large, it was thought that surveying the entire cohort of facilities would yield a more accurate picture of IC resources and practices. It was estimated that the time and resources needed to survey the entire population of facilities were not significantly greater than that needed to survey a sample. Using simple descriptive survey methodology, a wide range of IC resources and practices in Maryland was assessed. The senior ICPs in the facilities completed the survey during January 2003. The unit of analysis in this survey was the individual facility, regardless of the number of ICPs employed in that facility. Each facility was mailed one survey. The survey was intended to solicit the scope of responsibilities, the amount and types of support, and the range of certain IC practices among Maryland health care facilities, and included quantitative and qualitative components. The survey solicited information about the following: (1) basic facility characteristics and functions; (2) IC and health care epidemiology personnel; (3) IC organization within the facility; (4) committee service; (5) coverage responsibility of ICPs, ie, numbers of beds, ambulatory clinics, dialysis centers, etc; (6) support services available to ICPs; (7) types of surveillance activities and outbreak reporting procedures; (8) isolation capacity; (9) involvement in employee health programs; (10) emergency preparedness related to IC; and (11) education and training of ICPs. Half of the questions required discrete answers, ie, yes, no, or I don’t know, and the remaining half required narrative answers. The survey was pretested by two experienced ICPs from ACHs and two ICPs from LTCFs. This pretest assessed the survey instrument for clarity and content validity. The four ICPs rated the questions as clear and unambiguous; therefore, no changes were made in the
original wording of the questions. The content validity was assessed by having the ICPs match the survey questions with the objectives of the project, thus determining whether or not the information required was actually being solicited. The content validity index was 0.8, thus indicating that the survey measured what it proposed to measure, ie, the IC resources and practices present in several categories of Maryland health care facilities in 2003.7 Internal consistency reliability of the survey was greater than 0.70, indicating satisfactory reliability.8 The survey instrument was mailed to each ACH, LTCF, and specialty hospital in Maryland in January 2003. Each survey was accompanied by an explanatory letter that requested that the senior ICP of the facility complete the survey and return it by fax or in the enclosed self-addressed, stamped envelope. This first mailing of 307 surveys was completed by January 30, 2003. Three weeks after the initial mailing, a followup postcard was mailed to the 197 facilities that had not responded. The postcard reminders prompted 41 requests for a new survey, the initial one having been lost or mislaid. These were mailed by March 15, 2003. Data from responding facilities were entered into a spreadsheet program for descriptive statistics that included linear regression calculations. Data were analyzed separately for each type of facility, ie, ACHs with 200 or fewer beds, ACHs with more than 200 beds, LTCFs, and specialty hospitals. The x2 statistic for statistical significance was calculated with the Bonferroni correction for multiple comparisons.9
RESULTS Table 1 outlines response rates by type of facility. Three weeks after the initial mailing of surveys, and before the reminder postcards were sent, the initial overall response rate was 36%. The final overall response rate was 49% for all facilities surveyed. Of note, reminder postcards increased the overall response rate by 13%. Several important differences emerged after analysis of the responses. These differences included staffing patterns, training of ICPs, and the number and scope of non-ICP responsibilities. First, facilities differed markedly in their ICP staffing. Mean ICP staffing in ACHs with 200 or fewer beds was 1.6 full-time
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Fig 1. Acute hospital infection control professional full-time equivalent staff by beds.
Fig 2. Long-term care facility infection control professional full-time equivalent staff by beds. equivalent (FTE) positions per facility (range, 1 to 2 FTEs). ACHs of more than 200 beds reported a mean of 2.0 FTEs per facility (range, 1 to 6 FTEs). The correlation of ICP FTE staffing and bed size at ACHs is shown in Figure 1. Generally, ACH ICP staffing is strongly positively correlated with numbers of acute beds (Pearson correlation coefficient, r 5 0.92, P , .001). In a reanalysis of only those ACHs with fewer than 500 beds (to eliminate the outlier effects of Maryland’s largest and second largest ACHs), correlation of ICP FTE staffing with bed size remains highly positive (Pearson correlation coefficient, r 5 .75, P , .001). In marked contrast with ACHs, Figure 2 shows that there seems to be no significant correlation between the numbers of ICP FTEs at LTCFs and facility beds (Pearson correlation coefficient, r 5 0.17, P , .10). Of the 50% of responding LTCFs who answered that
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Fig 3. Organizational placement of infection control.
survey question, the mean number of ICP staff was 0.3 FTEs (range, 0.1 to 2.5 FTEs) for facilities ranging in size from 25 to 550 beds. Finally, the 13 specialty hospitals responding to this question reported mean ICP FTE staffing of 1.1 FTEs (range, 0.1 to 3 FTEs) for facilities covering a total of 41 to 412 acute and chronic licensed beds. There was only a moderate correlation between the numbers of beds in these facilities and ICP staffing (Pearson correlation coefficient, r 5 0.48, P , .2). Figure 3 shows the reporting relationships of IC programs within their facilities. A majority of ACHs of all sizes place ICPs organizationally under quality improvement programs. In contrast, ICPs in responding LTCFs and specialty hospitals have IC programs that report to nursing management. The survey also found differences in how frequently ICPs at different types of facilities are assigned to perform non-IC duties. When asked about assignment of non-IC duties to ICPs, 73% of ACHs with 200 or fewer beds answered yes and 24% of ACHs with more than 200 beds answered yes; for LTCFs, 95% answered yes; and for specialty hospitals, 79% answered yes. Overall, 89% of LTCFs, specialty hospitals, and ACHs with 200 or fewer beds assign their ICPs additional duties or non-IC functions. When asked to specify the nature of these other assigned duties, ICPs listed 31 other functions they were required to perform. In all ACHs and specialty hospitals, the predominant non-IC responsibility was for employee health activities. In LTCFs, the three most commonly reported non-IC functions were employee health, staff development, and quality improvement activities. In this State, it would not be unusual for a full-time RN in an LTCF to be expected to perform IC, employee health, staff development, and quality
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improvement activities, with only 10% to 20% of that position allotted for IC activities. Figure 4 shows the relative frequency of the eight most frequently reported non-IC responsibilities. In addition to these non-IC duties, ICPs in Maryland frequently have responsibility for IC activities in other facility components that are affiliated with or comprise parts of that health care facility or system. Table 2 lists these responsibilities for the four different types of facilities. For example, the median ICP responsibilities in an ACH with 200 or fewer beds includes 140 acute beds, 10 subacute or long-term care beds attached to the acute facility, 1 ambulatory surgery center, 1 other ambulatory clinic, and at least 1 physician’s office. For an ACH with more than 200 beds, these responsibilities increase to 292 acute beds, 15 long-term care beds, 1 drug treatment center, at least 1 large ambulatory surgical center, and at least 1 physician’s office. These IC duties are expected to be performed in addition to any non-IC duties that are assigned to the ICP. The survey also requested information about ICP participation in non-IC committees. Table 3 lists the various facility committees by type of facility in which Maryland ICPs participate. In ACHs, ICPs most often serve on safety, product evaluation, and disaster/ emergency preparedness committees. LTCF ICPs serve most often on quality assurance and safety committees. In specialty hospitals, ICPs serve most often on safety, product evaluation, and pharmacy and therapeutics committees. Survey findings about employee health responsibilities show that Maryland ICPs participate in a wide variety of functions related to disease screening and prevention and to exposure management. The most commonly reported activities in all facilities included placement and monitoring of tuberculosis skin tests, administration and compliance monitoring of hepatitis B and influenza vaccines, and management of postexposure prophylaxis for health care workers after a blood or body fluid exposure. Lastly, the survey solicited information about the basic IC training of ICPs working in health care facilities. All 55 responding ACHs and specialty hospitals (95%) have at least one ICP with basic IC training. In contrast, only 8 (8.0%) of 96 responding LTCFs have at least one ICP with basic IC training, such as that offered by the Association for Professionals in Infection Control and Epidemiology (APIC).
DISCUSSION Forty-nine percent of ACHs, LTCFs, and specialty hospitals in the state responded to the survey. A limitation of the survey is the lack of detailed information about those facilities who did not respond.
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Fig 4. Relative frequency of other responsibilities of infection control professionals.
For example, although 2 in 5 LTCFs responded to the survey, a preliminary analysis of the LTCF nonresponder group showed no significant differences between responders and nonresponders in relationship to geographic location in the state, the numbers of licensed beds, or whether or not the facility was part of an LTCF chain. Infections in LTCFs and other health care settings are important public health concerns. A review of DHMH data (unpublished) from reported outbreaks in LTCFs during the period of 1999 to 2003 showed that an average of more than 160 outbreaks of infectious diseases in LTCFs were reported each year and involved a total of more than 4,700 cases of illness. The occurrence of this large number of illnesses among such a vulnerable population represents a significant public health challenge. However, these survey results indicate that the individuals who are expected to prevent and manage outbreaks, ie, LTCF ICPs, are the ones with the least amount of IC training and the most demands on their time from non-IC duties. This is an ominous finding because many of today’s residents of LTCFs would have been acute hospitals patients as recently as 10 years ago.10 This increasing challenge of effectively providing the knowledge and skills needed to deal with IC issues in the LTCF setting is recognized at the national level. The Institute of Medicine’s Committee on Quality of Health Care in America reviewed this situation in the executive summary of their 2004 report11: . Like newly licensed physicians, newly licensed nurses need additional training and education once they enter the workforce [.] . experienced
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Table 2. Median coverage responsibilities of infection control professionals by facility type
Acute beds Long-term beds Drug treatment centers Dialysis centers Ambulatory surgery centers Other ambulatory clinics Physician offices Other facilities Mean infection control staff full-time equivalent positions
Acute care, 200 beds or fewer (n = 15)
Acute care, more than 200 beds (n = 21)
Long-term care facility (n = 96)
Specialty hospital (n = 19)
140 (20–200) 10 (0–69) 0 (0–5) 0 (0–15) 1 (0–6) 1 (0–4) 0 (0–1) 0 (0–1) 1.6 (1–2)
292 (233–1025) 15 (0–88) 1 (0–5) 1 (0–8) 1 (0–100) 1 (0–5) 1 (0–7) 2.5 (0–5) 2.0 (1–6)
100 (25–550) 0 (0–1) 0 (0–6) 0 (0–2) 0 (0–3) 0 (0–7) 0 (0–1) 0.3 (0.1–2.5)
97 (7–225) 106 (20–266) 0 (0–65) 0 (0–6) 0 (0–18) 0 (0–20) 0 (0–19) 0 (0–0) 1.1 (0.1–3)
Data given as n (range).
Table 3. Infection control professionals participation in non–infection control committees by facility* Committee involvement
Safety Quality assurance/improvement Disaster/emergency preparedness Product evaluation Pharmacy and therapeutics Construction/renovation planning Risk management Mortality review Prospective payment system
Acute # 200 (n = 15)
Acute . 200 (n = 21)
Long-term care facility (n = 96)
Specialty (n = 19)
Totaly (n = 151)
94 69 100 94 69 71 20 10 0
100 53 95 100 70 80 6 6 0
71 85 54 32 32 17 37 33 24
90 80 80 84 84 53 53 28 12
80 79 68 55 48 36 34 27 18
*Percent answering yes of facilities responding of that facility type. y Including all facility types.
nurses similarly need ongoing education and training to keep up with the continuing growth of new medical knowledge and technology. [H]ospitals are reported to have scaled back orientation programs for newly hired nurses, as well as ongoing in-service training and continuing education programs, as a result of financial pressures. The committee found evidence that all health care professionals (nurses and physicians alike) need better training, as well as organizational practices that promote and support interdisciplinary collaboration and teamwork. Although these comments go beyond the concerns of IC competency in all health care settings, they indicate the close connection between patient safety and effective ICP education. In summary, this survey of IC resources and practices in ACHs, LTCFs, and specialty hospitals in Maryland provides insight about current IC resources and practices in Maryland health care facilities. For example, survey results suggest that LTCFs could benefit from DHMH-approved IC training and from regulatory actions addressing ICP staffing pattern requirements. One immediate response to this need in Maryland
was the establishment in 2004 of a 3-day basic IC course with specific emphasis on IC in a nonhospital facility. Participants included ICPs from more than 86 LTCFs across the state, as well as communicable disease nurses from local health departments and nurse surveyors from the DHMH Office of Health Care Quality. A potential additional DHMH response to these IC program disparities is a new DHMH regulation that will require at least one individual who has basic IC training to be designated as the ICP at each LTCF facility in the state. This new regulation is currently under review by state officials. However, no recommendations have been made thus far concerning ICP-to-residents staffing patterns for LTCFs. These survey results and their implications will be disseminated to all health care facilities in Maryland in the near future, to be followed by the results and conclusions about public health’s need to develop and expand existing relationships with ICPs in health care facilities in Maryland. The authors thank the following for their support of this project: The Greater Baltimore Chapter, The Association for Professionals in Infection Control and Epidemiology (APIC); the ICPs at Maryland health care facilities who completed and returned the survey; Ms. Erika Kalp, MPH, and Ms. Kimberly Jones for data entry; and Ms. Pat Ryan for careful review of the manuscript.
Roup, Roche, and Pass References 1. Khabbaz R, Tenney J. Infection control in Maryland nursing homes. Infect Control Hosp Epidemiol 1988;9:159-62. 2. Morrison J, Health Canada, Nosocomial Occupational Infections Section. Development of a resource model for infection prevention and control programs in acute, long-term, and home care settings. Am J Infect Control 2004;32:2-6. 3. Friedman C, Barnette M, Buck A, Ham R, Harris J, Hoffman P, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings. Infect Control Hosp Epidemiol 1999;20:695-705. 4. Maryland Department of Health and Mental Hygiene, Vital Statistics Administration. Maryland vital statistics 2003 preliminary report. Baltimore, MD; August 2004. 5. Maryland Department of Health and Mental Hygiene, Office of Health Care Quality. Provider listings. Baltimore, MD; August 2004.
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6. Dunham A, Stricof R. Infection Control Resources. New York State Acute Care Facilities, 1999. Proceedings: Centers for Disease Control and Prevention 4th Decennial International Conference on Nosocomial and Health care-Associated Infections. Atlanta, GA; 1999. 7. Waltz C, Jenkins L. Measurement of nursing outcomes. New York: Springer Publishing; 2002. 8. Waltz C, Jenkins L. Measurement of nursing outcomes. New York: Springer Publishing; 2002. 9. Altman D. Practical statistics for medical research. London: Chapman and Hall; 1991. 10. Jarvis W. Infection control and changing health-care delivery systems. Emerg Infect Dis 2001;7:170-3. 11. Board on Health Care Services of the Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Excerpted from executive summary, pp. 1-22. Washington, DC: National Academies Press; 2004.