- Email: [email protected]
Identifying the gaps in infection prevention and control resources for long-term care facilities in British Columbia
American Journal of Infection Control 40 (2012) 150-4
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Identifying the gaps in infection prevention and control resources for long-term care facilities in British Columbia Bruce Gamage BSN, RN, CIC a, *, Valerie Schall MSc, RN b, Jennifer Grant MDCM, FRCPC, c, d the PICNet Long-term Care Needs Assessment Working Group a
Provincial Infection Control Network of British Columbia, Vancouver, British Columbia, Canada Douglas College, Burnaby, British Columbia, Canada Vancouver Coastal Health, Vancouver, British Columbia, Canada d University of British Columbia, Vancouver, British Columbia, Canada b c
Key Words: Infection control Resources Long-term care
Background: Infection prevention and control (IPC) is a critical, although often neglected, part of longterm care (LTC) management. Little is known about what IPC resources are available for LTC and how that impacts patient care and safety. Methods: One hundred eighty-eight LTC facilities were randomly selected out of all British Columbia facilities and surveyed using a validated survey tool. The tool was used to collect data regarding IPC resources grouped within 6 indices: (1) leadership, (2) infection control professionals (ICP) coverage, (3) policies and procedures, (4) support through partnerships, (5) surveillance, and (6) control activities. All components measured have been identified as key for an effective IPC program. Survey responses were used to calculate scores for IPC programs as a whole and for each of the 6 indices. Results: Of 188 randomly selected facilities, 86 institutions participated. Facilities were compared by region, funding source, and ICP coverage. Overall, LTC facilities lacked IPC leadership, especially physician support. Having no dedicated ICP was associated with poorer scores on all indices. Only 41% of practicing ICPs had more than 2 years experience, and only 14% were professionally certified. Twenty-two percent of ICPs had additional roles within the institution, and 44% had additional roles outside of the institution. Thirty-five percent of institutions had no IPC dedicated budget. Discussion: LTC institutionsdwith bed numbers exceeding those in acute caredrepresent an important aspect of health services. These data show that many LTC facilities lack the necessary resources to provide quality infection control programs. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Long-term and rehabilitative care (LTC) services represent an important aspect of health services bridging the community and acute care. These facilities provide 24-hour professional nursing care and supervision in a protective, supportive environment for people who have complex care needs and can no longer be cared for in their own homes. Infection prevention and control (IPC) resources in LTC have not kept pace with those in acute care, despite general agreement that infections represent a significant source of morbidity and mortality for the LTC facility residents.1
* Address correspondence to Bruce Gamage, BSN, RN, CIC, 655 W 12th Ave, Vancouver, BC V5Z 4R4, Canada. E-mail address: [email protected] (B. Gamage). Members of the PICNet Long-term Care Needs Assessment Working Group are listed in the Appendix. Conflicts of interest: None to report.
Although seniors living in LTC facilities are highly vulnerable to infection, research specifically related to IPC in LTC has been slow to progress. Although there are now recommendations from expert advisory groups describing IPC program organizational structures and activities that should be in place in LTC, these are largely based on extrapolations from structures and processes shown to be effective in acute care.2,3 This has occurred even though all expert groups agree that IPC programs and processes in LTC and acute care need to and should be fundamentally different.4 The Province of British Columbia (BC), Canada, with a population of just over 4 million, is serviced by 5 regional health authorities (HA), reporting to the Ministry of Health. Significant variation exists in the resources available to IPC in different geographical regions of BC, particularly those dedicated to LTC. These differences affect facilities ability to implement recommended infection prevention and control practices. Variations also
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.03.026
B. Gamage et al. / American Journal of Infection Control 40 (2012) 150-4
occur in the funding model for LTC facilities in BC. Some facilities are owned and operated by the health region, others are under contract to the health region to provide services, and some are independent of the health region. The purpose of this study was to gain a clearer understanding of the differences in IPC structures and processes in LTC among regions and under the various funding models. This information could then identify the strengths and gaps in our current model to ensure that safe, high-quality care is provided to all LTC residents. METHODS
151
Table 1 Index scores Scores Indices Total infection control score Leadership index ICP Index Policy and strategy index Partnership and resource index Surveillance index Control index
Mean score (%)
SD
55.0 37.5 45.2 67.5 61.3 56.1 56.7
15.7 19.2 26.6 19.3 18.7 23.8 19.8
ICP, infection control professional; SD, standard deviation. 5
A validated survey recently developed in BC to evaluate IPC structures and processes was reviewed by a group of 23 experts in LTC IPC. The survey was then transformed into an online electronic format. A random sample of 188 LTC facilities stratified by health region was then selected out of the 800 LTC facilities in BC. To protect against the possibility of confounders (eg, variations in IPC funding, in resident populations living in LTC, or in environmental factors), stratified randomization by HA was used. Forty facilities from each of the 5 HA were randomly selected. The sample size for each HA was calculated based on the assumption that IPC structures and processes within facilities from each ownership type are similar. Most facilities are either owned and operated or contracted by HAs, and all of these facilities receive IPC support from the health region. A maximum variation of 30% was therefore estimated within groups. According to a recent BC study,6 there is a significant association between health regions in BC and IPC resources in acute care. Rural regions of the province were found to have fewer experienced infection control professionals (ICP) and limited access to physicians with IPC expertise. Because there is currently no literature describing the degree of regional variation in IPC resources in the LTC setting in BC, the sample size was calculated for a 95% probability of detecting a minimum difference of 20% among the 5 HAs and allowing for a 20% probability of making a type II error. The minimum required sample size was calculated as 18, but this was increased to 40 to account for nonresponders and to provide a margin of error in our estimates. Each of the 5 random samples of facilities was obtained using the program Research Randomizer (Social Psychology Network, Middletown, CT). In the fall of 2009, the facilities were invited to participate in the study via letters of invitation from the investigators. A link to the validated Web-based survey and a cover letter was then e-mailed to each facility. Telephone reminders were used to enhance response rate. The survey included 63 questions on 6 key indicators (called indices) of IPC. These 6 indices included (1) The “Leadership Index,” a measure of resources such as an IPC physician, an IPC committee, and a clear IPC leadership structure within the facility; (2) the “Infection Control Professional (ICP) Index,” a description of the amount and type of ICP support available; (3) the “Policy and Strategy Index,” a measure of the completeness of policies and strategies relevant to infection control within the facility; (4) the “Partnership and Resources Index,” a measure of the presence of relevant internal and external resources for infection control; (5) the “Surveillance Index,” a comparison of surveillance activities to recommended standards; and (6) the “Control Index,” a comparison of IPC strategies used in the facility to recommended standards. In addition, a “Total Infection Control Score” was calculated from all of the 6 indices. Each of the components of the 6 multifactorial indices listed above was identified in national and international guidelines and literature for effective IPC programs in LTC settings.7-9 Prior to this study, the face and content validity of the survey were tested using
the Delphi methodology with a panel of experts in LTC infection prevention and control. The survey was also pilot tested to further establish its validity and feasibility. A copy of the survey is available on request to [email protected]. The senior manager with the greatest knowledge of the IPC program within each facility was invited to participate in the study. In most facilities (63%), the administrator who responded to the survey named themselves as the person responsible for IPC. In cases in which the administrator named another person as ICP when answering the survey (ie, either someone within the facility or a regional ICP), a second survey was administered to the ICP named by the administrator. The responses from the second survey were used to verify the responses of the administrator respondent. Where differences were found in the 2 sets of responses, the responses from the person named as ICP were used to calculate the index scores for the facility. Facility scores and responses were compared by region, funding source, and ICP availability. Survey responses were collected electronically, using a password-protected, Web-based form. The responses were analyzed using the 6 indices above by assigning point values to each response. Point values were awarded based on the components established in national or international guidelines or through consensus of the expert working group. Partial points were awarded for graded responses (eg, 0 points for never/rarely, 0.5 for sometimes, 1 point for always). Index values are presented as percentages of a total possible score; therefore, the maximum value for each index is 100. The “Total Infection Control Score” for each facility was calculated by adding the 6 index scores and dividing the result by 6. This calculation resulted in individual facility “Infection Control Scores” with a maximum value of 100. Finally, subcomponents of each index were also analyzed to identify gaps in resources. Data analysis was performed using SPSS for Windows (IBM, Armonk, NY).
RESULTS At the time the survey was conducted, 800 residential care facilities were operating in the province of BC. One hundred eightyeight facilities from the 5 geographical health care regions in BC were randomly selected to participate. A comparison between the characteristics of all residential care facilities in BC’s HA and the facilities sampled for this survey was done for mean bed numbers and funding model. For those facilities where these characteristics were known, no statistically significant differences were observed between the mean bed numbers (P ¼ .80) and the mean percentage of facilities within the different funding models (P ¼ .74). Eighty-six institutions responded to the online survey (46% response rate) of which 79% submitted complete surveys. Fifty percent of the responding facilities were directly funded by their regional Health Authority through government funding; 22%
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B. Gamage et al. / American Journal of Infection Control 40 (2012) 150-4
Fig 1. Distribution of leadership index score by health region.
received government funding indirectly through contracts with the HA; 27% of facilities operated solely on private funding. Responding facilities housed mainly long-term care beds, but some also housed complex care and assisted living beds. The mean number of long-term care beds in responding facilities was 93.5 (standard deviation [SD], 68.9). This was higher than the mean bed number for the province, 72.6 (SD, 27.9) as per data provided by the BC Ministry of Health.
Index scores The mean index scores, for all respondents are shown in Table 1. Overall infection control scores are poor (55%), with the lowest scores in the Leadership Index (37%) and the highest for the Policy and Strategy Index (67%).
Leadership index Only 5% of facilities had a dedicated physician with IPC responsibilities, whereas 58% of facilities had no infection control physician support of any kind. The remainder could access an infection control physician on a consulting basis. Forty percent of responding facilities reported that physician support was provided for less than 30 minutes per month. The availability of an infection control committee to address issues within the facility also varied. Thirtyone percent of respondents reported having a local committee, while 22% stated they had access to a regional committee. Twentyfive percent of respondents reported no infection control committee at all. The Vancouver Coastal (mean, 46%) and Fraser Health (mean, 41%) regions, the 2 most densely populated regions in BC, tended to have higher Leadership index scores than other BC regions. This is illustrated in Figure 1. One-way analysis of variance statistical testing showed that the variance among health regions had a strong statistical significance (F score ¼ 3.09 [P value < .05]).
Surveillance and control indices The Surveillance and Control indices measure the facility’s compliance with nationally and internationally recommended surveillance and infection control practices. LTC facilities across BC are using only 56% (SD, 23.7%) of recommended surveillance activities and only 56% (SD, 19.8%) of recommended infection control activities. Funding source was not found to be a significant contributor to the overall quality of the IPC program. The mean infection control scores and distribution of scores for those facilities that receive direct funding, contract funding, and private funding were not significantly different. Infection control professional index Thirty-six percent of facilities reported access to on-site ICP support, while 17% reported no ICP support of any kind. Figure 2 illustrates the type of ICP support available to the responding facilities. Thirty-two percent of respondents were unsure of the amount of ICP support their facility was receiving from their regional health authority. Responses from facility administrators greatly overestimated the activities performed by regional ICPs (eg, IPC product selection, preparation, and review of IPC reports). In addition, 22% of ICPs had additional roles within the institution, and 44% had additional roles outside of the institution. Only 41% of practicing ICPs had more than 2 years experience, and only 14% achieved certification in infection control through the Certification Board for Infection Control and Epidemiology (CIC). Policy index On average, facilities obtained their highest scores in this index, with 67% of the respondents reporting having recommended IPC policies in place (SD, 29.3%). The weakest scores in this index were related to emergency preparedness (mean, 64.6%). These results
B. Gamage et al. / American Journal of Infection Control 40 (2012) 150-4
153
40 35 30
Percent
25 20 15 10 5 0 ICP working from within ICP assigned by Health the facility Authority
ICP from Health Authority available for consultation
No ICP support at all
Unknown
Fig 2. Type of ICP support.
were observed during the fall/winter of 2009-2010 when pandemic influenza was spreading across the province. Internal/external partnerships and material resources index Facilities reported that, on average, they had established 61% of the key partnerships (eg, laboratory, pharmacy, public health) and material resources required for IPC support (SD, 18.7%). However, only 52% of key external partnerships were reported as being used, and 35% of facilities had no dedicated IPC budget. Discussion Several priorities were identified as gaps that need to be addressed for the resident safety and quality of care in LTC facilities in BC to improve. Although most facilities had established many of the policies and procedures required for IPC, they seemed to be missing much of the structures and leadership required to implement them effectively over the long term. The vast majority of facilities have little or no access to a physician to assist them with their infection control strategies. Access to such a physician with training in IPC has been shown to be a key component of a successful IPC program. The HA should explore strategies to provide greater access to physicians with specialized training through sharing of resources and greater collaboration among HA. With respect to the person identified as the “ICP,” who is responsible for implementing IPC policies in the facility, they often have very little training, experience, or support. In addition, they are burdened with many other roles and responsibilities, making it very difficult to focus on their IPC duties. In all indices measured, the presence of an ICP on-site was shown to improve the quality of IPC programs within facilities. Facilities with an on-site ICP scored highest on the Leadership index (44%), followed by facilities with an ICP assigned by the HA (43%), and facilities with access to an ICP only for consultations (37%). Facilities with no ICP resources (22%) had the lowest scores. Having no ICP, either on-site or through the health region, was associated with a lower IPC program score. Similarly, much poorer scores on the surveillance and control indices were measured for facilities without access to an ICP onsite. When only regional ICP support was provided, administrators seemed to demonstrate a lack of understanding of the extent of support provided by the regional ICP. This lack of clarity may give these administrators a false sense of the adequacy of their IPC program.
The recommended ratio for ICPs in LTC is 1 ICP per 250 beds.10 This recommendation should take into account the complexity of care provided in the facility and should consider the scope of service provision and the geographic separation between work sites within each HA. The education and training for designated ICP staff in LTC should be included as part of strategic planning activities and quality management initiatives. Professional development plans should reflect the needs of the individual and the practice setting and/or background individuals bring to the role. Funding should be provided for infection control education/training to ensure that opportunities are available and that minimum education standards for education/training must be flexible enough to address recruitment challenges. Professional qualifications are both an indication of ICP competence and of institutional support for professional development. The low rate of CIC certification indicates that ICPs are not being sufficiently supported to develop and maintain internationally recognized standards. LTC facilities across BC are using only 56% of recommended surveillance activities. Surveillance for antibiotic-resistant organisms and Clostridium difficile are required operational practices for Accreditation Canada. HAs should review epidemiologic services available to LTC facilities and devise a plan to provide epidemiologic services to all facilities to assist in developing a comprehensive and consistent surveillance program. Training on surveillance data collection should be provided to the person identified as responsible for IPC, and the use of shared databases should be encouraged wherever possible. Use of electronic data capture and existing electronic information should be employed wherever possible to minimize duplication of effort. The lack of emergency preparedness was particularly concerning in our findings. The establishment of more effective IPC structure (eg, IPC committee, ICP with few other responsibilities) and practices (eg, surveillance) would also assist facilities in planning for an eventual emergency such as a pandemic of influenza. Because this was a voluntary survey with a response rate of 46%, it should be noted that there may have been differences between the facilities that responded to the survey and those that did not respond. We were unable to analyze these differences because the facilities that responded did so anonymously, except to note that, in general, respondents were from institutions with a larger number of beds. This may bias our results because those facilities with larger bed numbers may be better resourced and therefore more likely to respond. Regardless of the above limitations, our findings show that many LTC facilities lack the necessary resources to provide quality
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infection control programs. Although many of the facilities had established IPC policies and external partnerships to assist them with IPC issues that arise, most lacked the leadership and administrative support required to sustain an effective, high-quality IPC program. In 1991, the Harvard Medical Practice Study II on patient safety published results showing that wound infections were the second most common type of health care-associated adverse events.11 Patient safety literature describes preventable health care-associated infections as adverse events related to or caused by errors embedded in institutional or clinical processes. Ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur.12 Therefore, the authors of the Harvard Medical Practice Study II concluded that IPC improvements were a critical method of reducing risk of infection-related adverse events. It is evident that the gaps in LTC infection prevention and control resources across BC need to be addressed in order for the resident safety and quality of care to improve. The findings of this study also highlight the importance of evaluating the resources available to LTC facilities in any geographic location. The method and survey used in this study provide a feasible, reliable, and valid way of obtaining this valuable data and could be used in any other location for the same purpose. It could also be used in conjunction with quality and safety indicators to evaluate the relative effectiveness of various structures and processes currently used in IPC. The work completed in this study was the first step toward ensuring that preventable infections are effectively avoided within all LTC facilities. Continued evaluation and research will now be required to achieve positive change. References 1. Smith PW, Bennet G, Bradley S, Drinka P, Lautenbach E, Marx J, et al. SDEA/APIC Guideline: infection prevention and control in the long-term care facility. Am J Infect Control 2008;36:509-35.
2. Smith PW, Rusnak PG. Special communication. Infection prevention and control in the long-term care facility. Am J Infect Control 1997;25:488-512. 3. Jenkinson H, Wright D, Jones M, Diaz E, Pronyszyn A, Hughes K, et al. Prevention and control of infection in non-acute healthcare settings. Nursing Stand 2006;20:56-66. 4. Nicolle LE. Infection control in long-term care facilities. Clin Infect Dis 2000;31: 752-6. 5. Schall V. Infection prevention and control effectiveness and safety: validation of a survey for long-term care facilities. Library Archives Canada: Theses, Canada. UBC 2008. Available from: http://www.collectionscanada.gc.ca/obj/s4/ f2/dsk3/BVAU/TC-BVAU-944.pdf. Accessed September 29, 2010. 6. Gamage B, Pugh S, Litt M, Bryce E. A survey of infection prevention and control resources in acute care facilities across British Columbia. Can J Infect Control 24:213-8. 7. Stevenson K, Loeb M. Performance improvement in the long-term-care setting: building on the foundation of infection control. Infect Control Hosp Epidemiol 2004;25:72. 8. Handler SM, Castle NG, Studenski SA, Perara S, Fridsma DB, Nace DA, et al. Patient safety culture assessment in the nursing home. Qual Saf Health Care 2006;15:400-4. 9. Richards C. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc 2002;50:570-6. 10. Morrison J. Development of a resource model for infection prevention and control programs in acute, long-term, and home care settings: conference proceedings of the Infection Prevention And Control Alliance. Am J Infect Control 2004;32:2-6. 11. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard medical practice study II. N Engl J Med 1991;324:377-84. 12. Agency for Healthcare Research and Quality. AHRQ Quality Indicators-Guide to patient safety indicators. Rockville [MD]: Agency for Healthcare Research and Quality, 2003.
APPENDIX. MEMBERS OF THE PICNET LONG-TERM CARE NEEDS ASSESSMENT WORKING GROUP Joanne Archer, Dr Rèka Gustafson, Susan Higginbotham, Dr Bonnie Henry, Louise Holmes, Suzanne Hyderman, Shannon Johnson, Angela Long, Andrea Neil, Holly-Lynn Nelson, Avril Macdonald, Wanda Murphy, Cathy Munford, Jackie Ratzlaff, Rashpal Toor, Dawn Vallee, Lorraine Wentland, Kathy Wong, Lisa Young.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Identifying the gaps in infection prevention and control resources for long-term care facilities in British Columbia Bruce Gamage BSN, RN, CIC a, *, Valerie Schall MSc, RN b, Jennifer Grant MDCM, FRCPC, c, d the PICNet Long-term Care Needs Assessment Working Group a
Provincial Infection Control Network of British Columbia, Vancouver, British Columbia, Canada Douglas College, Burnaby, British Columbia, Canada Vancouver Coastal Health, Vancouver, British Columbia, Canada d University of British Columbia, Vancouver, British Columbia, Canada b c
Key Words: Infection control Resources Long-term care
Background: Infection prevention and control (IPC) is a critical, although often neglected, part of longterm care (LTC) management. Little is known about what IPC resources are available for LTC and how that impacts patient care and safety. Methods: One hundred eighty-eight LTC facilities were randomly selected out of all British Columbia facilities and surveyed using a validated survey tool. The tool was used to collect data regarding IPC resources grouped within 6 indices: (1) leadership, (2) infection control professionals (ICP) coverage, (3) policies and procedures, (4) support through partnerships, (5) surveillance, and (6) control activities. All components measured have been identified as key for an effective IPC program. Survey responses were used to calculate scores for IPC programs as a whole and for each of the 6 indices. Results: Of 188 randomly selected facilities, 86 institutions participated. Facilities were compared by region, funding source, and ICP coverage. Overall, LTC facilities lacked IPC leadership, especially physician support. Having no dedicated ICP was associated with poorer scores on all indices. Only 41% of practicing ICPs had more than 2 years experience, and only 14% were professionally certified. Twenty-two percent of ICPs had additional roles within the institution, and 44% had additional roles outside of the institution. Thirty-five percent of institutions had no IPC dedicated budget. Discussion: LTC institutionsdwith bed numbers exceeding those in acute caredrepresent an important aspect of health services. These data show that many LTC facilities lack the necessary resources to provide quality infection control programs. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Long-term and rehabilitative care (LTC) services represent an important aspect of health services bridging the community and acute care. These facilities provide 24-hour professional nursing care and supervision in a protective, supportive environment for people who have complex care needs and can no longer be cared for in their own homes. Infection prevention and control (IPC) resources in LTC have not kept pace with those in acute care, despite general agreement that infections represent a significant source of morbidity and mortality for the LTC facility residents.1
* Address correspondence to Bruce Gamage, BSN, RN, CIC, 655 W 12th Ave, Vancouver, BC V5Z 4R4, Canada. E-mail address: [email protected] (B. Gamage). Members of the PICNet Long-term Care Needs Assessment Working Group are listed in the Appendix. Conflicts of interest: None to report.
Although seniors living in LTC facilities are highly vulnerable to infection, research specifically related to IPC in LTC has been slow to progress. Although there are now recommendations from expert advisory groups describing IPC program organizational structures and activities that should be in place in LTC, these are largely based on extrapolations from structures and processes shown to be effective in acute care.2,3 This has occurred even though all expert groups agree that IPC programs and processes in LTC and acute care need to and should be fundamentally different.4 The Province of British Columbia (BC), Canada, with a population of just over 4 million, is serviced by 5 regional health authorities (HA), reporting to the Ministry of Health. Significant variation exists in the resources available to IPC in different geographical regions of BC, particularly those dedicated to LTC. These differences affect facilities ability to implement recommended infection prevention and control practices. Variations also
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.03.026
B. Gamage et al. / American Journal of Infection Control 40 (2012) 150-4
occur in the funding model for LTC facilities in BC. Some facilities are owned and operated by the health region, others are under contract to the health region to provide services, and some are independent of the health region. The purpose of this study was to gain a clearer understanding of the differences in IPC structures and processes in LTC among regions and under the various funding models. This information could then identify the strengths and gaps in our current model to ensure that safe, high-quality care is provided to all LTC residents. METHODS
151
Table 1 Index scores Scores Indices Total infection control score Leadership index ICP Index Policy and strategy index Partnership and resource index Surveillance index Control index
Mean score (%)
SD
55.0 37.5 45.2 67.5 61.3 56.1 56.7
15.7 19.2 26.6 19.3 18.7 23.8 19.8
ICP, infection control professional; SD, standard deviation. 5
A validated survey recently developed in BC to evaluate IPC structures and processes was reviewed by a group of 23 experts in LTC IPC. The survey was then transformed into an online electronic format. A random sample of 188 LTC facilities stratified by health region was then selected out of the 800 LTC facilities in BC. To protect against the possibility of confounders (eg, variations in IPC funding, in resident populations living in LTC, or in environmental factors), stratified randomization by HA was used. Forty facilities from each of the 5 HA were randomly selected. The sample size for each HA was calculated based on the assumption that IPC structures and processes within facilities from each ownership type are similar. Most facilities are either owned and operated or contracted by HAs, and all of these facilities receive IPC support from the health region. A maximum variation of 30% was therefore estimated within groups. According to a recent BC study,6 there is a significant association between health regions in BC and IPC resources in acute care. Rural regions of the province were found to have fewer experienced infection control professionals (ICP) and limited access to physicians with IPC expertise. Because there is currently no literature describing the degree of regional variation in IPC resources in the LTC setting in BC, the sample size was calculated for a 95% probability of detecting a minimum difference of 20% among the 5 HAs and allowing for a 20% probability of making a type II error. The minimum required sample size was calculated as 18, but this was increased to 40 to account for nonresponders and to provide a margin of error in our estimates. Each of the 5 random samples of facilities was obtained using the program Research Randomizer (Social Psychology Network, Middletown, CT). In the fall of 2009, the facilities were invited to participate in the study via letters of invitation from the investigators. A link to the validated Web-based survey and a cover letter was then e-mailed to each facility. Telephone reminders were used to enhance response rate. The survey included 63 questions on 6 key indicators (called indices) of IPC. These 6 indices included (1) The “Leadership Index,” a measure of resources such as an IPC physician, an IPC committee, and a clear IPC leadership structure within the facility; (2) the “Infection Control Professional (ICP) Index,” a description of the amount and type of ICP support available; (3) the “Policy and Strategy Index,” a measure of the completeness of policies and strategies relevant to infection control within the facility; (4) the “Partnership and Resources Index,” a measure of the presence of relevant internal and external resources for infection control; (5) the “Surveillance Index,” a comparison of surveillance activities to recommended standards; and (6) the “Control Index,” a comparison of IPC strategies used in the facility to recommended standards. In addition, a “Total Infection Control Score” was calculated from all of the 6 indices. Each of the components of the 6 multifactorial indices listed above was identified in national and international guidelines and literature for effective IPC programs in LTC settings.7-9 Prior to this study, the face and content validity of the survey were tested using
the Delphi methodology with a panel of experts in LTC infection prevention and control. The survey was also pilot tested to further establish its validity and feasibility. A copy of the survey is available on request to [email protected]. The senior manager with the greatest knowledge of the IPC program within each facility was invited to participate in the study. In most facilities (63%), the administrator who responded to the survey named themselves as the person responsible for IPC. In cases in which the administrator named another person as ICP when answering the survey (ie, either someone within the facility or a regional ICP), a second survey was administered to the ICP named by the administrator. The responses from the second survey were used to verify the responses of the administrator respondent. Where differences were found in the 2 sets of responses, the responses from the person named as ICP were used to calculate the index scores for the facility. Facility scores and responses were compared by region, funding source, and ICP availability. Survey responses were collected electronically, using a password-protected, Web-based form. The responses were analyzed using the 6 indices above by assigning point values to each response. Point values were awarded based on the components established in national or international guidelines or through consensus of the expert working group. Partial points were awarded for graded responses (eg, 0 points for never/rarely, 0.5 for sometimes, 1 point for always). Index values are presented as percentages of a total possible score; therefore, the maximum value for each index is 100. The “Total Infection Control Score” for each facility was calculated by adding the 6 index scores and dividing the result by 6. This calculation resulted in individual facility “Infection Control Scores” with a maximum value of 100. Finally, subcomponents of each index were also analyzed to identify gaps in resources. Data analysis was performed using SPSS for Windows (IBM, Armonk, NY).
RESULTS At the time the survey was conducted, 800 residential care facilities were operating in the province of BC. One hundred eightyeight facilities from the 5 geographical health care regions in BC were randomly selected to participate. A comparison between the characteristics of all residential care facilities in BC’s HA and the facilities sampled for this survey was done for mean bed numbers and funding model. For those facilities where these characteristics were known, no statistically significant differences were observed between the mean bed numbers (P ¼ .80) and the mean percentage of facilities within the different funding models (P ¼ .74). Eighty-six institutions responded to the online survey (46% response rate) of which 79% submitted complete surveys. Fifty percent of the responding facilities were directly funded by their regional Health Authority through government funding; 22%
152
B. Gamage et al. / American Journal of Infection Control 40 (2012) 150-4
Fig 1. Distribution of leadership index score by health region.
received government funding indirectly through contracts with the HA; 27% of facilities operated solely on private funding. Responding facilities housed mainly long-term care beds, but some also housed complex care and assisted living beds. The mean number of long-term care beds in responding facilities was 93.5 (standard deviation [SD], 68.9). This was higher than the mean bed number for the province, 72.6 (SD, 27.9) as per data provided by the BC Ministry of Health.
Index scores The mean index scores, for all respondents are shown in Table 1. Overall infection control scores are poor (55%), with the lowest scores in the Leadership Index (37%) and the highest for the Policy and Strategy Index (67%).
Leadership index Only 5% of facilities had a dedicated physician with IPC responsibilities, whereas 58% of facilities had no infection control physician support of any kind. The remainder could access an infection control physician on a consulting basis. Forty percent of responding facilities reported that physician support was provided for less than 30 minutes per month. The availability of an infection control committee to address issues within the facility also varied. Thirtyone percent of respondents reported having a local committee, while 22% stated they had access to a regional committee. Twentyfive percent of respondents reported no infection control committee at all. The Vancouver Coastal (mean, 46%) and Fraser Health (mean, 41%) regions, the 2 most densely populated regions in BC, tended to have higher Leadership index scores than other BC regions. This is illustrated in Figure 1. One-way analysis of variance statistical testing showed that the variance among health regions had a strong statistical significance (F score ¼ 3.09 [P value < .05]).
Surveillance and control indices The Surveillance and Control indices measure the facility’s compliance with nationally and internationally recommended surveillance and infection control practices. LTC facilities across BC are using only 56% (SD, 23.7%) of recommended surveillance activities and only 56% (SD, 19.8%) of recommended infection control activities. Funding source was not found to be a significant contributor to the overall quality of the IPC program. The mean infection control scores and distribution of scores for those facilities that receive direct funding, contract funding, and private funding were not significantly different. Infection control professional index Thirty-six percent of facilities reported access to on-site ICP support, while 17% reported no ICP support of any kind. Figure 2 illustrates the type of ICP support available to the responding facilities. Thirty-two percent of respondents were unsure of the amount of ICP support their facility was receiving from their regional health authority. Responses from facility administrators greatly overestimated the activities performed by regional ICPs (eg, IPC product selection, preparation, and review of IPC reports). In addition, 22% of ICPs had additional roles within the institution, and 44% had additional roles outside of the institution. Only 41% of practicing ICPs had more than 2 years experience, and only 14% achieved certification in infection control through the Certification Board for Infection Control and Epidemiology (CIC). Policy index On average, facilities obtained their highest scores in this index, with 67% of the respondents reporting having recommended IPC policies in place (SD, 29.3%). The weakest scores in this index were related to emergency preparedness (mean, 64.6%). These results
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40 35 30
Percent
25 20 15 10 5 0 ICP working from within ICP assigned by Health the facility Authority
ICP from Health Authority available for consultation
No ICP support at all
Unknown
Fig 2. Type of ICP support.
were observed during the fall/winter of 2009-2010 when pandemic influenza was spreading across the province. Internal/external partnerships and material resources index Facilities reported that, on average, they had established 61% of the key partnerships (eg, laboratory, pharmacy, public health) and material resources required for IPC support (SD, 18.7%). However, only 52% of key external partnerships were reported as being used, and 35% of facilities had no dedicated IPC budget. Discussion Several priorities were identified as gaps that need to be addressed for the resident safety and quality of care in LTC facilities in BC to improve. Although most facilities had established many of the policies and procedures required for IPC, they seemed to be missing much of the structures and leadership required to implement them effectively over the long term. The vast majority of facilities have little or no access to a physician to assist them with their infection control strategies. Access to such a physician with training in IPC has been shown to be a key component of a successful IPC program. The HA should explore strategies to provide greater access to physicians with specialized training through sharing of resources and greater collaboration among HA. With respect to the person identified as the “ICP,” who is responsible for implementing IPC policies in the facility, they often have very little training, experience, or support. In addition, they are burdened with many other roles and responsibilities, making it very difficult to focus on their IPC duties. In all indices measured, the presence of an ICP on-site was shown to improve the quality of IPC programs within facilities. Facilities with an on-site ICP scored highest on the Leadership index (44%), followed by facilities with an ICP assigned by the HA (43%), and facilities with access to an ICP only for consultations (37%). Facilities with no ICP resources (22%) had the lowest scores. Having no ICP, either on-site or through the health region, was associated with a lower IPC program score. Similarly, much poorer scores on the surveillance and control indices were measured for facilities without access to an ICP onsite. When only regional ICP support was provided, administrators seemed to demonstrate a lack of understanding of the extent of support provided by the regional ICP. This lack of clarity may give these administrators a false sense of the adequacy of their IPC program.
The recommended ratio for ICPs in LTC is 1 ICP per 250 beds.10 This recommendation should take into account the complexity of care provided in the facility and should consider the scope of service provision and the geographic separation between work sites within each HA. The education and training for designated ICP staff in LTC should be included as part of strategic planning activities and quality management initiatives. Professional development plans should reflect the needs of the individual and the practice setting and/or background individuals bring to the role. Funding should be provided for infection control education/training to ensure that opportunities are available and that minimum education standards for education/training must be flexible enough to address recruitment challenges. Professional qualifications are both an indication of ICP competence and of institutional support for professional development. The low rate of CIC certification indicates that ICPs are not being sufficiently supported to develop and maintain internationally recognized standards. LTC facilities across BC are using only 56% of recommended surveillance activities. Surveillance for antibiotic-resistant organisms and Clostridium difficile are required operational practices for Accreditation Canada. HAs should review epidemiologic services available to LTC facilities and devise a plan to provide epidemiologic services to all facilities to assist in developing a comprehensive and consistent surveillance program. Training on surveillance data collection should be provided to the person identified as responsible for IPC, and the use of shared databases should be encouraged wherever possible. Use of electronic data capture and existing electronic information should be employed wherever possible to minimize duplication of effort. The lack of emergency preparedness was particularly concerning in our findings. The establishment of more effective IPC structure (eg, IPC committee, ICP with few other responsibilities) and practices (eg, surveillance) would also assist facilities in planning for an eventual emergency such as a pandemic of influenza. Because this was a voluntary survey with a response rate of 46%, it should be noted that there may have been differences between the facilities that responded to the survey and those that did not respond. We were unable to analyze these differences because the facilities that responded did so anonymously, except to note that, in general, respondents were from institutions with a larger number of beds. This may bias our results because those facilities with larger bed numbers may be better resourced and therefore more likely to respond. Regardless of the above limitations, our findings show that many LTC facilities lack the necessary resources to provide quality
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infection control programs. Although many of the facilities had established IPC policies and external partnerships to assist them with IPC issues that arise, most lacked the leadership and administrative support required to sustain an effective, high-quality IPC program. In 1991, the Harvard Medical Practice Study II on patient safety published results showing that wound infections were the second most common type of health care-associated adverse events.11 Patient safety literature describes preventable health care-associated infections as adverse events related to or caused by errors embedded in institutional or clinical processes. Ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur.12 Therefore, the authors of the Harvard Medical Practice Study II concluded that IPC improvements were a critical method of reducing risk of infection-related adverse events. It is evident that the gaps in LTC infection prevention and control resources across BC need to be addressed in order for the resident safety and quality of care to improve. The findings of this study also highlight the importance of evaluating the resources available to LTC facilities in any geographic location. The method and survey used in this study provide a feasible, reliable, and valid way of obtaining this valuable data and could be used in any other location for the same purpose. It could also be used in conjunction with quality and safety indicators to evaluate the relative effectiveness of various structures and processes currently used in IPC. The work completed in this study was the first step toward ensuring that preventable infections are effectively avoided within all LTC facilities. Continued evaluation and research will now be required to achieve positive change. References 1. Smith PW, Bennet G, Bradley S, Drinka P, Lautenbach E, Marx J, et al. SDEA/APIC Guideline: infection prevention and control in the long-term care facility. Am J Infect Control 2008;36:509-35.
2. Smith PW, Rusnak PG. Special communication. Infection prevention and control in the long-term care facility. Am J Infect Control 1997;25:488-512. 3. Jenkinson H, Wright D, Jones M, Diaz E, Pronyszyn A, Hughes K, et al. Prevention and control of infection in non-acute healthcare settings. Nursing Stand 2006;20:56-66. 4. Nicolle LE. Infection control in long-term care facilities. Clin Infect Dis 2000;31: 752-6. 5. Schall V. Infection prevention and control effectiveness and safety: validation of a survey for long-term care facilities. Library Archives Canada: Theses, Canada. UBC 2008. Available from: http://www.collectionscanada.gc.ca/obj/s4/ f2/dsk3/BVAU/TC-BVAU-944.pdf. Accessed September 29, 2010. 6. Gamage B, Pugh S, Litt M, Bryce E. A survey of infection prevention and control resources in acute care facilities across British Columbia. Can J Infect Control 24:213-8. 7. Stevenson K, Loeb M. Performance improvement in the long-term-care setting: building on the foundation of infection control. Infect Control Hosp Epidemiol 2004;25:72. 8. Handler SM, Castle NG, Studenski SA, Perara S, Fridsma DB, Nace DA, et al. Patient safety culture assessment in the nursing home. Qual Saf Health Care 2006;15:400-4. 9. Richards C. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc 2002;50:570-6. 10. Morrison J. Development of a resource model for infection prevention and control programs in acute, long-term, and home care settings: conference proceedings of the Infection Prevention And Control Alliance. Am J Infect Control 2004;32:2-6. 11. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard medical practice study II. N Engl J Med 1991;324:377-84. 12. Agency for Healthcare Research and Quality. AHRQ Quality Indicators-Guide to patient safety indicators. Rockville [MD]: Agency for Healthcare Research and Quality, 2003.
APPENDIX. MEMBERS OF THE PICNET LONG-TERM CARE NEEDS ASSESSMENT WORKING GROUP Joanne Archer, Dr Rèka Gustafson, Susan Higginbotham, Dr Bonnie Henry, Louise Holmes, Suzanne Hyderman, Shannon Johnson, Angela Long, Andrea Neil, Holly-Lynn Nelson, Avril Macdonald, Wanda Murphy, Cathy Munford, Jackie Ratzlaff, Rashpal Toor, Dawn Vallee, Lorraine Wentland, Kathy Wong, Lisa Young.