- Email: [email protected]
Infection surveillance and control programs in the Department of Veterans Affairs nursing home care units: A preliminary assessment
Infection surveillance and control programs in the Department of Veterans Affairs nursing home care units: A preliminary assessment Linda Tsan, MD,a Christa Hojlo, RN, DNSc,a Martha A. Kearns, RN, MSN, FNP,a Chester Davis, PhD,a Robert Langberg,a Maurice Claggett,a Nancy Coughlin, RN,a Michael Miller, MD, PhD,b Robert Gaynes, MD,c Cynthia Gibert, MD,d Ona Montgomery, RN,e Chesley Richards, MD,f Linda Danko, RN,a,g and Gary Roselle, MDa,g Washington, District of Columbia; Bedford, Massachusetts; Atlanta, Georgia; Amarillo, Texas; and Cincinnati, Ohio
A survey was conducted to assess the capacity and current practices of the infection surveillance and control programs at the Department of Veterans Affairs’ 130 nursing home care units (VA NHCUs) covering a total of 15,006 beds in 2003. All 130 VA NHCUs responded to the survey, although not all NHCUs answered every question. The majority of the VA NHCUs provided specialized services that might pose increased risks of infection. For every 8 to 10 VA NHCU beds, there was 1 regular-pressure or negative-pressure infection control room available. Each VA NHCU had an active ongoing infection surveillance and control program managed by highly educated infection control personnel (ICP), of which 96% had a minimum of a bachelor degree. A median of 12 hours per week of these ICP efforts was devoted to the infection surveillance and control activities. The most frequently used surveillance methods were targeted surveillance for specific infections and for specific organisms. Most VA NHCUs conducted surveillance for antibiotic-resistant organisms. However, VA NHCUs did not use a uniform set of definitions for nosocomial infections for their infection surveillance and control purposes. We conclude that VA NHCUs have a considerable infrastructure and capacity for infection surveillance and control. This information can be used to develop a nationwide VA NHCU nosocomial infection surveillance system. (Am J Infect Control 2006;34:80-3.)
The Study on the Efficacy of Nosocomial Infection Control (SENIC) conducted by the Centers for Disease Control and Prevention (CDC) in the mid-1970s has clearly demonstrated that an effective surveillance and control program can reduce the rates of nosocomial infections in acute care hospitals.1 Although no comparable studies have been carried out in long-term care facilities (LTCFs), the risk of acquiring an infection in the LTCFs appears to be comparable with that of acute care hospitals.2-4 In 1989, the Health Care Financing Administration, now the Center for Medicaid/Medicare Services (CMS), mandated that LTCFs maintain From the Department of Veterans Affairs Central Office, Washington, DCa; Veterans Integrated Services Network No. 1, Bedford, MAb; Veterans Affairs Medical Center, Atlanta, GAc; Veterans Affairs Medical Center, Washington, DCd; Veterans Affairs Medical Center, Amarillo, TXe; Centers for Disease Control and Prevention, Atlanta, GAf; and Veterans Affairs Medical Center, Cincinnati, OH.g Reprint requests: Linda Tsan, MD, Office of Medical Inspector (10MI), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420. E-mail: [email protected]. The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. 0196-6553/$32.00 Copyright ª 2006 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2005.10.001
80
programs to investigate, control, and prevent infections, eg, infection surveillance and control programs.5 During the past 2 decades, the emergence of the HIV/ AIDS epidemic, multidrug-resistant microorganisms, and emerging pathogens, as well as the changes in the US health care system, have markedly increased the complexity of infection surveillance and control programs, resulting in an increased demand of infection control personnel (ICP). In 1985, the SENIC report suggested that optimal staffing for infection control programs was 1 ICP for every 250 occupied beds in acute care facilities.1 However, a recent Delphi panel recommended 1 full-time equivalent (FTE) ICP for each 100 occupied beds in both acute care and LTCFs.6 Likewise, the Canadian Infection Prevention and Control Alliance recommended 3 FTE ICP for each 500 acute care hospital beds and 1 FTE ICP for 150 to 250 LTCF beds.7 As the largest single provider of health care in the United States, the Veterans Health Administration, Department of Veterans Affairs, operates 163 hospitals and 130 nursing home care units (NHCUs) throughout the country. As part of planning to establish a nationwide VA NHCU nosocomial infections surveillance system similar to the CDC’s National Nosocomial Infections Surveillance System,8 we first conducted a Nursing Home Infection Surveillance (NHIS) survey of the VA NHCUs. The purpose was to assess the current
Tsan et al
March 2006
Table 1. VA nursing home care unit bed size Operating beds, n 1-50 51-100 101-150 151-200 .200 Total
VA nursing home care units, n (%) 24 (18) 35 (27) 35 (27) 18 (14) 18 (14) 130 (100)
capacity and practices of the VA NHCU infection control programs.
81
Table 2. Special services provided by VA nursing home care units VA nursing home care Special services units
Yes
No
No response
IV chemotherapy IV therapy Ventilator care Wound care Specialized postoperative care Other special services*
17 123 18 129 41 60
104 6 102 0 80 35
9 1 10 1 9 35
*Other special services included pre-/posttransplant care, hemodialysis, peritoneal dialysis, radiation therapy, tracheostomy, central lines, infusion pumps, and blood transfusions.
METHODS A nursing home infection surveillance task force that consisted of VA Central Office and Veterans Integrated Service Network personnel and field experts in infectious disease and infection control as well as representatives from the CDC was formed to conduct this survey. The task force first developed a 10-question survey and pilot tested it in 6 VA NHCUs. It was then transformed into a Web-based survey and distributed to all 130 VA NHCUs in September 2003. The survey questionnaire was designed to collect information on employee influenza vaccination rate, use of the CMS Minimum Data Set (MDS),9 infection isolation rooms, special services provided, location in relation to VA hospitals, qualification of ICP and their efforts devoted to NHCU infection control activities, definition of infection surveillance used, surveillance processes, targets, and organisms. Completed surveys were submitted electronically to the VA central office, at which data were entered into a computerized database for analysis. All 130 NHCUs responded to the survey. However, not all NHCUs provided answers to every question. In addition, the number of operating beds in each NHCU at the end of fiscal year 2003 was obtained from the VA database at Austin, TX. Only descriptive statistics were presented.
RESULTS Characteristics of VA NHCUs The Department of Veterans Affairs operated 130 NHCUs, of which 108 NHCUs (83%) were located on VA hospital campuses, whereas 22 NHCUs (17%) were free standing, not on any VA hospital campus. As shown in Table 1, the size of VA NHCUs varied from less than 50 beds to over 200 beds. Fifty-four percent (54%) of the VA NHCUs were between 50 and 150 beds. As shown in Table 2, VA NHCUs provided a variety of special services. In general, NHCUs located on a VA hospital campus were more likely to provide higher level special services. For example, 16 of the 17 NHCUs
providing chemotherapy, and 16 of the 18 providing ventilator support services were located on a VA hospital campus. A total of 114 NHCUs responded to the question on the number of single rooms with private sink and toilet that can be used as infection isolation rooms. Among 12,538 beds in these 114 NHCUs, there were 1404 negative-pressure and regular-pressure infection isolation rooms available. Of the 36 NHCUs with negative-pressure isolation room capability, the ratio of negativepressure infection isolation rooms to NHCU beds was 1:8; of the 78 NHCUs with only regular-pressure room capacity, the ratio of regular-pressure infection isolation rooms to NHCU beds was 1:10.
ICP The number of ICP devoted to infection control programs at VA NHCUs could not be obtained accurately because most VA NHCU infection control programs were part of the hospital’s overall infection control programs. Therefore, we obtained information on the number of hours devoted to NHCU infection control activities by ICP and their qualifications. Of the 125 NHCUs that responded, the nationwide median number of hours allocated for the NHCU infection control program was 12 hours per week (interquartile range of 5-20 hours per week). NHCUs that were not located on a hospital campus reported a median of 20 hours per week of ICP effort devoted to infection control program, whereas those on the hospital campus reported a median of 10 hours per week. Of the 130 NHCUs that responded to the question on qualification of their ICP, 48% had a doctoral degree, 21% a masters degree, 27% a bachelor degree (including registered nurses; RN), 3% of RN without a bachelor degree, and 1% an associate degree.
Infection surveillance and control practices Definition of infection. All 130 NHCUs responded to the question on the definition of infection used for
82
Tsan et al
Vol. 34 No. 2
infection surveillance. Eighty-nine utilized the CDC definition of nosocomial infections,10 whereas 34 utilized the McGeer definition (the Canadian definitions for nosocomial infections in LTCFs),11 19 reported using the modified McGeer definition, 30 using the modified CDC definition, and 57 used more than 1 set of definitions. See the cited references for detailed descriptions of the CDC and McGeer definitions. Infection surveillance. All 130 NHCUs responded to the question on the method of surveillance. VA NHCUs most frequently used targeted surveillance methods of specific infections (86%) and specific organisms (82%). The frequencies of combined periodic and continuous surveillance methods used were incidence surveillance (total), 39%; incidence surveillance (whole house), 38%; targeted surveillance (specific infections), 86%; targeted surveillance (specific patients), 35%; targeted surveillance (specific organisms), 82%; and process surveillance, 38%. Among the targeted surveillance for specific body sites, the frequencies of combined periodic and continuous surveillance were urinary tract, 86%; lower respiratory tract, 83%, upper respiratory tract, 68%; skin and soft tissue, 59%; bloodstream primary, 86%; bloodstream secondary, 76%; gastrointestinal tract, 79%; surgical site, 72%; and eye, 52%. Among the 17 NHCUs that provided intravenous (IV) chemotherapy services, all (100%) conducted bloodstream primary surveillance. One hundred six (86%) of the 130 NHCUs that provided IV therapy services conducted bloodstream primary surveillance. Seventeen (94%) of the 18 NHCUs that provided ventilator support services performed lower respiratory tract surveillance. The frequencies of combined periodic and continuous surveillance for vancomycin-resistant Staphylococcus aureaus (SARV) was 70%; methicillin-resistant S aureus (MRSA), 95%; vancomycin-resistant enterococcus (VRE), 93%; Clostridium difficile, 93%; penicillin-resistant Streptococcus pneumoniae, 87%; and multidrug-resistant (MDR) Pseudomonas aeruginosa, 82%. Influenza vaccination. Of the 118 NHCUs that responded, the median rate of NHCU staff, part-time or full-time employees, having received influenza vaccination during the winter of 2002-2003 was 45%, with an interquartile range of 30% to 60%. The actual vaccination rate could have been higher because some employees might have been vaccinated at sites other than the VA, and those data were not available. Resident assessment instrument/minimum data set (RAI/MDS). The Department of Veterans Affairs mandated that all VA NHCUs use RAI/CMS MDS.12 One hundred twenty-nine NHCUs reported the use of RAI/MDS and transmitted the information electronically to the VA Austin data center.
DISCUSSION The purpose of this limited survey is to obtain information regarding the current capacity and practices of the VA NHCU infection surveillance and control program to develop a nationwide VA NHCU nosocomial infections surveillance system. It was not the intention of this survey to assess the efficacy of nosocomial infection control in VA NHCUs. Nonetheless, a number of conclusions can be derived from these data. First, the majority of VA NHCUs provided some type of complex, specialized services associated with a known increased risk of nosocomial infections. In general, NHCUs located on a VA hospital campus were more likely to provide higher level specialized services such as chemotherapy and ventilator support services. Second, for every 8 to 10 VA NHCU beds, there was 1 regular-pressure or negative-pressure infection isolation room available. Third, regardless of whether it was located on the VA hospital campus, each VA NHCU appeared to have an active ongoing infection surveillance and control program run by highly educated ICP, of which 96% had a minimum of a bachelor degree. A median of 12 hours per week of these ICP efforts was devoted to infection surveillance and control activities at the VA NHCUs. NHCUs that were not located on a hospital campus devoted a median of 20 hours per week, whereas those on the hospital campus devoted a median of 10 hours per week, to the infection control program. The reason for this difference is not clear, but it may be due to the fact that the infection control program at NHCUs that were located on a hospital campus were usually conducted as a part of the overall hospital infection control program. The most frequently used surveillance methods were targeted surveillance for specific infections and for specific organisms. Most VA NHCUs conducted surveillance for antibioticresistant organisms. However, VA NHCUs did not use a uniform set of definitions for nosocomial infections for their infection surveillance and control purposes. Thus, even though VA NHCUs had a considerable infrastructure and capacity for infection surveillance and control programs, there is a need to standardize the definition of nosocomial infections and the surveillance approach in the future. The CDC’s National Nosocomial Infections Surveillance (NNIS) system is the nation’s largest and oldest performance system devoted to hospital-acquired infections. Significant decreases in infection in the intensive care units and surgical patients have occurred at NNIS hospitals during the past 30 years.13 There has been no similar nosocomial infections surveillance system for LTCFs. The development of such a system for VA NHCUs will facilitate uniform surveillance of nosocomial infections at VA NHCUs and contribute
Tsan et al
significantly to a reduction in the rates of these infections. The results of the current survey provide basic information that will be useful for the development of a VA NHCU nosocomial infections surveillance system. Given the fact that the VA is the single largest provider of nursing home care in the United States, such a surveillance system could serve as a model for nursing home surveillance of nosocomial infections for all nursing homes and significantly contribute to improving patient care.
March 2006
5. 6.
7.
8. The authors thank Clark Sawin, MD, of the Department of Veterans Affairs for his contribution to the work presented here.
References 1. Culver D, White J, Morgan WM, Emori TG, Munn VP, Hooton TP. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121: 182-205. 2. Setia U, Serventi I, Lorenz P. Nosocomial infections among patients in a long-term care facility: spectrum, prevalence, and risk factors. Am J Infect Control 1985;13:57-62. 3. Smith P. Infection surveillance in long-term care facilities. Infect Control Hosp Epidemiol 1991;12:55-8. 4. Beck-Sague C, Villarino E, Giuliano D, Welbel S, Latts L, Manangan L, et al. Infectious diseases and death among nursing home residents:
9. 10. 11.
12. 13.
83
results of surveillance in 13 nursing homes. Infect Control Hosp Epidemiol 1994;15:494-6. Health Care Financing Administration. Requirement for long-term care facilities. Federal Register 1989;54:5359-73. O’Boyle CA, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control 2002;30:321-33. Health Canada, Division of Occupational and Nosocomial Infections. 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. Can J Infect Control 2001;16:35-9. Sartor C, Edwards JR, Gaynes RP, Culver D. National Nosocomial Infections Surveillance System. Evolution of hospital participation in the National Nosocomial Infections Surveillance System, 1986-1993. Am J Infect Control 1995;23:364-8. Zimmerman DR. Development and testing of nursing home quality indicators. Health Care Financing Reform 1995;16:107-27. Garner JS, Jarvis WR, Emori TG, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control 1988;16:128-40. McGeer A, Campbell B, Emori TG, Hierholzer W, Jackson M, Nicolle L, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19:1-7. Veterans Health Administration Directive 2001-029, Resident assessment instrument minimum data set (RAI/MDS). May 12, 2001. Centers for Disease Control and Prevention. Monitoring hospitalacquired infections to promote patient safety-United States, 19901999. MMWR Morb Mortal Wkly Rep 2000;49:149-53.
A survey was conducted to assess the capacity and current practices of the infection surveillance and control programs at the Department of Veterans Affairs’ 130 nursing home care units (VA NHCUs) covering a total of 15,006 beds in 2003. All 130 VA NHCUs responded to the survey, although not all NHCUs answered every question. The majority of the VA NHCUs provided specialized services that might pose increased risks of infection. For every 8 to 10 VA NHCU beds, there was 1 regular-pressure or negative-pressure infection control room available. Each VA NHCU had an active ongoing infection surveillance and control program managed by highly educated infection control personnel (ICP), of which 96% had a minimum of a bachelor degree. A median of 12 hours per week of these ICP efforts was devoted to the infection surveillance and control activities. The most frequently used surveillance methods were targeted surveillance for specific infections and for specific organisms. Most VA NHCUs conducted surveillance for antibiotic-resistant organisms. However, VA NHCUs did not use a uniform set of definitions for nosocomial infections for their infection surveillance and control purposes. We conclude that VA NHCUs have a considerable infrastructure and capacity for infection surveillance and control. This information can be used to develop a nationwide VA NHCU nosocomial infection surveillance system. (Am J Infect Control 2006;34:80-3.)
The Study on the Efficacy of Nosocomial Infection Control (SENIC) conducted by the Centers for Disease Control and Prevention (CDC) in the mid-1970s has clearly demonstrated that an effective surveillance and control program can reduce the rates of nosocomial infections in acute care hospitals.1 Although no comparable studies have been carried out in long-term care facilities (LTCFs), the risk of acquiring an infection in the LTCFs appears to be comparable with that of acute care hospitals.2-4 In 1989, the Health Care Financing Administration, now the Center for Medicaid/Medicare Services (CMS), mandated that LTCFs maintain From the Department of Veterans Affairs Central Office, Washington, DCa; Veterans Integrated Services Network No. 1, Bedford, MAb; Veterans Affairs Medical Center, Atlanta, GAc; Veterans Affairs Medical Center, Washington, DCd; Veterans Affairs Medical Center, Amarillo, TXe; Centers for Disease Control and Prevention, Atlanta, GAf; and Veterans Affairs Medical Center, Cincinnati, OH.g Reprint requests: Linda Tsan, MD, Office of Medical Inspector (10MI), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420. E-mail: [email protected]. The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. 0196-6553/$32.00 Copyright ª 2006 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2005.10.001
80
programs to investigate, control, and prevent infections, eg, infection surveillance and control programs.5 During the past 2 decades, the emergence of the HIV/ AIDS epidemic, multidrug-resistant microorganisms, and emerging pathogens, as well as the changes in the US health care system, have markedly increased the complexity of infection surveillance and control programs, resulting in an increased demand of infection control personnel (ICP). In 1985, the SENIC report suggested that optimal staffing for infection control programs was 1 ICP for every 250 occupied beds in acute care facilities.1 However, a recent Delphi panel recommended 1 full-time equivalent (FTE) ICP for each 100 occupied beds in both acute care and LTCFs.6 Likewise, the Canadian Infection Prevention and Control Alliance recommended 3 FTE ICP for each 500 acute care hospital beds and 1 FTE ICP for 150 to 250 LTCF beds.7 As the largest single provider of health care in the United States, the Veterans Health Administration, Department of Veterans Affairs, operates 163 hospitals and 130 nursing home care units (NHCUs) throughout the country. As part of planning to establish a nationwide VA NHCU nosocomial infections surveillance system similar to the CDC’s National Nosocomial Infections Surveillance System,8 we first conducted a Nursing Home Infection Surveillance (NHIS) survey of the VA NHCUs. The purpose was to assess the current
Tsan et al
March 2006
Table 1. VA nursing home care unit bed size Operating beds, n 1-50 51-100 101-150 151-200 .200 Total
VA nursing home care units, n (%) 24 (18) 35 (27) 35 (27) 18 (14) 18 (14) 130 (100)
capacity and practices of the VA NHCU infection control programs.
81
Table 2. Special services provided by VA nursing home care units VA nursing home care Special services units
Yes
No
No response
IV chemotherapy IV therapy Ventilator care Wound care Specialized postoperative care Other special services*
17 123 18 129 41 60
104 6 102 0 80 35
9 1 10 1 9 35
*Other special services included pre-/posttransplant care, hemodialysis, peritoneal dialysis, radiation therapy, tracheostomy, central lines, infusion pumps, and blood transfusions.
METHODS A nursing home infection surveillance task force that consisted of VA Central Office and Veterans Integrated Service Network personnel and field experts in infectious disease and infection control as well as representatives from the CDC was formed to conduct this survey. The task force first developed a 10-question survey and pilot tested it in 6 VA NHCUs. It was then transformed into a Web-based survey and distributed to all 130 VA NHCUs in September 2003. The survey questionnaire was designed to collect information on employee influenza vaccination rate, use of the CMS Minimum Data Set (MDS),9 infection isolation rooms, special services provided, location in relation to VA hospitals, qualification of ICP and their efforts devoted to NHCU infection control activities, definition of infection surveillance used, surveillance processes, targets, and organisms. Completed surveys were submitted electronically to the VA central office, at which data were entered into a computerized database for analysis. All 130 NHCUs responded to the survey. However, not all NHCUs provided answers to every question. In addition, the number of operating beds in each NHCU at the end of fiscal year 2003 was obtained from the VA database at Austin, TX. Only descriptive statistics were presented.
RESULTS Characteristics of VA NHCUs The Department of Veterans Affairs operated 130 NHCUs, of which 108 NHCUs (83%) were located on VA hospital campuses, whereas 22 NHCUs (17%) were free standing, not on any VA hospital campus. As shown in Table 1, the size of VA NHCUs varied from less than 50 beds to over 200 beds. Fifty-four percent (54%) of the VA NHCUs were between 50 and 150 beds. As shown in Table 2, VA NHCUs provided a variety of special services. In general, NHCUs located on a VA hospital campus were more likely to provide higher level special services. For example, 16 of the 17 NHCUs
providing chemotherapy, and 16 of the 18 providing ventilator support services were located on a VA hospital campus. A total of 114 NHCUs responded to the question on the number of single rooms with private sink and toilet that can be used as infection isolation rooms. Among 12,538 beds in these 114 NHCUs, there were 1404 negative-pressure and regular-pressure infection isolation rooms available. Of the 36 NHCUs with negative-pressure isolation room capability, the ratio of negativepressure infection isolation rooms to NHCU beds was 1:8; of the 78 NHCUs with only regular-pressure room capacity, the ratio of regular-pressure infection isolation rooms to NHCU beds was 1:10.
ICP The number of ICP devoted to infection control programs at VA NHCUs could not be obtained accurately because most VA NHCU infection control programs were part of the hospital’s overall infection control programs. Therefore, we obtained information on the number of hours devoted to NHCU infection control activities by ICP and their qualifications. Of the 125 NHCUs that responded, the nationwide median number of hours allocated for the NHCU infection control program was 12 hours per week (interquartile range of 5-20 hours per week). NHCUs that were not located on a hospital campus reported a median of 20 hours per week of ICP effort devoted to infection control program, whereas those on the hospital campus reported a median of 10 hours per week. Of the 130 NHCUs that responded to the question on qualification of their ICP, 48% had a doctoral degree, 21% a masters degree, 27% a bachelor degree (including registered nurses; RN), 3% of RN without a bachelor degree, and 1% an associate degree.
Infection surveillance and control practices Definition of infection. All 130 NHCUs responded to the question on the definition of infection used for
82
Tsan et al
Vol. 34 No. 2
infection surveillance. Eighty-nine utilized the CDC definition of nosocomial infections,10 whereas 34 utilized the McGeer definition (the Canadian definitions for nosocomial infections in LTCFs),11 19 reported using the modified McGeer definition, 30 using the modified CDC definition, and 57 used more than 1 set of definitions. See the cited references for detailed descriptions of the CDC and McGeer definitions. Infection surveillance. All 130 NHCUs responded to the question on the method of surveillance. VA NHCUs most frequently used targeted surveillance methods of specific infections (86%) and specific organisms (82%). The frequencies of combined periodic and continuous surveillance methods used were incidence surveillance (total), 39%; incidence surveillance (whole house), 38%; targeted surveillance (specific infections), 86%; targeted surveillance (specific patients), 35%; targeted surveillance (specific organisms), 82%; and process surveillance, 38%. Among the targeted surveillance for specific body sites, the frequencies of combined periodic and continuous surveillance were urinary tract, 86%; lower respiratory tract, 83%, upper respiratory tract, 68%; skin and soft tissue, 59%; bloodstream primary, 86%; bloodstream secondary, 76%; gastrointestinal tract, 79%; surgical site, 72%; and eye, 52%. Among the 17 NHCUs that provided intravenous (IV) chemotherapy services, all (100%) conducted bloodstream primary surveillance. One hundred six (86%) of the 130 NHCUs that provided IV therapy services conducted bloodstream primary surveillance. Seventeen (94%) of the 18 NHCUs that provided ventilator support services performed lower respiratory tract surveillance. The frequencies of combined periodic and continuous surveillance for vancomycin-resistant Staphylococcus aureaus (SARV) was 70%; methicillin-resistant S aureus (MRSA), 95%; vancomycin-resistant enterococcus (VRE), 93%; Clostridium difficile, 93%; penicillin-resistant Streptococcus pneumoniae, 87%; and multidrug-resistant (MDR) Pseudomonas aeruginosa, 82%. Influenza vaccination. Of the 118 NHCUs that responded, the median rate of NHCU staff, part-time or full-time employees, having received influenza vaccination during the winter of 2002-2003 was 45%, with an interquartile range of 30% to 60%. The actual vaccination rate could have been higher because some employees might have been vaccinated at sites other than the VA, and those data were not available. Resident assessment instrument/minimum data set (RAI/MDS). The Department of Veterans Affairs mandated that all VA NHCUs use RAI/CMS MDS.12 One hundred twenty-nine NHCUs reported the use of RAI/MDS and transmitted the information electronically to the VA Austin data center.
DISCUSSION The purpose of this limited survey is to obtain information regarding the current capacity and practices of the VA NHCU infection surveillance and control program to develop a nationwide VA NHCU nosocomial infections surveillance system. It was not the intention of this survey to assess the efficacy of nosocomial infection control in VA NHCUs. Nonetheless, a number of conclusions can be derived from these data. First, the majority of VA NHCUs provided some type of complex, specialized services associated with a known increased risk of nosocomial infections. In general, NHCUs located on a VA hospital campus were more likely to provide higher level specialized services such as chemotherapy and ventilator support services. Second, for every 8 to 10 VA NHCU beds, there was 1 regular-pressure or negative-pressure infection isolation room available. Third, regardless of whether it was located on the VA hospital campus, each VA NHCU appeared to have an active ongoing infection surveillance and control program run by highly educated ICP, of which 96% had a minimum of a bachelor degree. A median of 12 hours per week of these ICP efforts was devoted to infection surveillance and control activities at the VA NHCUs. NHCUs that were not located on a hospital campus devoted a median of 20 hours per week, whereas those on the hospital campus devoted a median of 10 hours per week, to the infection control program. The reason for this difference is not clear, but it may be due to the fact that the infection control program at NHCUs that were located on a hospital campus were usually conducted as a part of the overall hospital infection control program. The most frequently used surveillance methods were targeted surveillance for specific infections and for specific organisms. Most VA NHCUs conducted surveillance for antibioticresistant organisms. However, VA NHCUs did not use a uniform set of definitions for nosocomial infections for their infection surveillance and control purposes. Thus, even though VA NHCUs had a considerable infrastructure and capacity for infection surveillance and control programs, there is a need to standardize the definition of nosocomial infections and the surveillance approach in the future. The CDC’s National Nosocomial Infections Surveillance (NNIS) system is the nation’s largest and oldest performance system devoted to hospital-acquired infections. Significant decreases in infection in the intensive care units and surgical patients have occurred at NNIS hospitals during the past 30 years.13 There has been no similar nosocomial infections surveillance system for LTCFs. The development of such a system for VA NHCUs will facilitate uniform surveillance of nosocomial infections at VA NHCUs and contribute
Tsan et al
significantly to a reduction in the rates of these infections. The results of the current survey provide basic information that will be useful for the development of a VA NHCU nosocomial infections surveillance system. Given the fact that the VA is the single largest provider of nursing home care in the United States, such a surveillance system could serve as a model for nursing home surveillance of nosocomial infections for all nursing homes and significantly contribute to improving patient care.
March 2006
5. 6.
7.
8. The authors thank Clark Sawin, MD, of the Department of Veterans Affairs for his contribution to the work presented here.
References 1. Culver D, White J, Morgan WM, Emori TG, Munn VP, Hooton TP. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121: 182-205. 2. Setia U, Serventi I, Lorenz P. Nosocomial infections among patients in a long-term care facility: spectrum, prevalence, and risk factors. Am J Infect Control 1985;13:57-62. 3. Smith P. Infection surveillance in long-term care facilities. Infect Control Hosp Epidemiol 1991;12:55-8. 4. Beck-Sague C, Villarino E, Giuliano D, Welbel S, Latts L, Manangan L, et al. Infectious diseases and death among nursing home residents:
9. 10. 11.
12. 13.
83
results of surveillance in 13 nursing homes. Infect Control Hosp Epidemiol 1994;15:494-6. Health Care Financing Administration. Requirement for long-term care facilities. Federal Register 1989;54:5359-73. O’Boyle CA, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control 2002;30:321-33. Health Canada, Division of Occupational and Nosocomial Infections. 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. Can J Infect Control 2001;16:35-9. Sartor C, Edwards JR, Gaynes RP, Culver D. National Nosocomial Infections Surveillance System. Evolution of hospital participation in the National Nosocomial Infections Surveillance System, 1986-1993. Am J Infect Control 1995;23:364-8. Zimmerman DR. Development and testing of nursing home quality indicators. Health Care Financing Reform 1995;16:107-27. Garner JS, Jarvis WR, Emori TG, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control 1988;16:128-40. McGeer A, Campbell B, Emori TG, Hierholzer W, Jackson M, Nicolle L, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19:1-7. Veterans Health Administration Directive 2001-029, Resident assessment instrument minimum data set (RAI/MDS). May 12, 2001. Centers for Disease Control and Prevention. Monitoring hospitalacquired infections to promote patient safety-United States, 19901999. MMWR Morb Mortal Wkly Rep 2000;49:149-53.