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Minding our business designing an infection control program
Minding Our Business
Designing an Infection Control Program BY SYLVIA HERRICK, RN, MS, AND KAREN M. LOOS, BS, MPH
LACK OF RESEARCH AND SUPPORT Research data on infection control in the home care setting have always been very limited. Only recently have a few studies appeared in the literature.’ Those of us who have worked in home care for a number of years would agree that hospital infection control studies, research results, and surveillance practices have little relevance for home care. In addition, many freestanding home care agencies have limited infection control or epidemiology expertise within their staff or such staff available to them regularly, although hospital-based home care services are often an exception to this.
BUSINESS
RECENT CHANGES IN HEALTH CARE AND HOME CARE Added to this are the following challenges arising from changes in the delivery of health care and in the home care environment within the last few years.2 -% The drive to reduce the cost of bealtb cure in this country: Home care agencies are seeing more acutely ill ADDRESS FOR CORRESPONDENCE: Sylvia Herrick, RN, MS, or KarenM. Loos,BS, MPH Visiting Nurse Associationand Hospiceof Northern California 1900 PowellSt., Suite 300 Emeryville, CA94608
MAY/JUNE
1996,
VOL. 1 NO.
3
patients, especially those with a need for hightech services. These patients are more likely to require or recently to have had invasive procedures, exposing them to the increased possibility of infection. Also, the current managed care environment, with its greater emphasis on improved patient outcomes as well as cost containment, necessitates a very efficient infection control system Recent emerging ePidemiologicfactors in this couvrtvy: Within the last 10 years, there has been an increase in the number of patients with active tuberculosis, especially in urban areas where there are more immigrants and in the patient population with AIDS, who generally are more susceptible to tuberculosis. There has been a gradual increase in the numbers of patients with AIDS and other patients being treated at home and requiring high-tech procedures that previously were done in hospitals.5 Many of these procedures increase the potential for patient infections and for employee exposure to infections. Examples include aerosolized pentamidine treatments, blood product transfusions, chemotherapy administration, and bone marrow transplant follow-up. The increase in the numbers of drugresistant organisms complicates infection control procedures for all levels of the health care system, especially protocols for antibiotic use. Increased uwareness on the part of the public and home care workers regarding tbe spread of infections atid a concem HOME
CARE PROVIDER
153
MINDING
HERRICK AND LOOS
OUR BUSINESS
for protection from exposl*re: This has led to an increased public demand for infection surveillance in home care and for effective protocols to protect patients and staff from exposure.
PROLIFERATION
OF EXTERNAL
REGULATllONS Perhaps the greatest impact on current infection control systems is the proliferation of national and state regulations affecting home care, resulting in part from the factors just discussed. Just 7 or 8 years ago, there were almost no regulations regarding infection control in home care, and there was little surveillance and very little public concern.6.9 Since then, voluntary accrediting agencies, such as the Joint Commission on the Accreditation of Healthcare Organizations and the Community Health Accreditation Program, Inc., have set and upgraded standards for surveillance, prevention, and control of infections. The Occupational Safety and Health Administration (OSHA) also sets standards for the protection of workers, including those in the health care field. OSHA regulations include exposure control standards for tuberculosis, as well as the original control standards for blood borne pathogens. In addition, many states have laws to protect health care workers and the public from disease; for example, laws regulating medical waste management. These laws affect home care practice in the areas of providing care, educating patients, and transporting and tracking waste.
ESSENTIAL
PROGRAM
COMPONENTS
Designing an infection control system that adequately addresses these constraints and requirements is a challenge for today’s home care agency. A number of minimal components that address the current issues are required for home care infection control programs, and these are listed in the box.
DESCRIPTION
OF VNAHNC’S
PROGRAM
Visiting Nurse Association and Hospice of Northern California (VNAHNC) developed a home care infection control program, which evolved over the last 7 or 8 years and which is cost-effective, meets regulations, and focuses on maintenance or improvement in significant, high-risk areas. VNAHNC has grown in the last 7 years from 85,000 to more than 300,000 visits per year and includes multiple programs and delivery sites. This rapid growth contributed as much to the necessity for the infection control program as did the other factors already discussed. Though the program continues to evolve, a description of the structure and components of the current system follows.
Control
and Coordination
VNAHNC’s infection control program is directed and coordinated by a committee composed of management and staff. They report to an overall advisory and quality 154
HOME
CARE PROVIDER
management committee, the Professional and Quality Advisory Committee, which has community and provider as well as agency staff members and which ultimately reports to the board of trustees of VNAHNC.
Committee
Composition
The Infection Control Committee includes representatives from clinical operations, quality management (QM), education, clinical staff, and materials management. Members also represent the major programs in VNAHNC, including hospice, infusion therapy, perinatal/pediatric, and home care. The committee chairperson is a clinical manager who brings the necessary clinical and operational expertise and who communicates with the rest of the management team. Other staff attend as the agendas require. For example, a human resources department representative may participate in decisions regarding employee tuberculosis testing. The committee size ranges from five to eight members, and each member may represent more than one area; for example, clinical operations and home infusion.
Committee
Functions
The Infection Control Committee is responsible for the following: l Setting infection control program goals l Developing, regularly updating, and tracking adherence to exposure prevention and infection control policies and procedures MAY/JUNE
1996,
VOL.
t NO.3
MINDING
l
l
l l
OUR BUSINESS
Outlining and assisting in implementing mandated infection control-related education programs Designing and maintaining an infection surveillance system Analyzing and tracking infection patterns Recommending products that relate to infection control
Specific examples of how some of these functions are carried out are as follows: The committee annually revises VNAHNC’s Infection arrd ExposureControl Guidelinesand coordinates education for staff regarding these policies. l The group plans the required tuberculosis and blood borne pathogens educational updates. * Members developed a system to evaluate adherence to infection control policies and procedures in the field. Although the QM department collects data from checklists completed during supervisory visits, it is the committee that regularly reviews this summary for trends. l The committee developed an infection surveillance system to track infection patterns. The current system consists of an annual infection point prevalence study to obtain infection rates, and a few discrete projects focusing on high-risk areas to track for trends and possible improvement needs. These high-risk project areas include (I) employee purified protein derivative conversion rates, (2) employee blood and body fluid exposure rates, (3) vascular access device complications, and (4) vancomycin use patterns. These projects were chosen because they focus on some of the current concerns in infection control. They include hightech invasive care, increases in drug-resistant organl
MAY/JUNE
1996,
VOL.
1 NO. 3
HERRICK AND LOOS
isms, and employee concern for protection from exposure to disease. This “improvement project approach” fits the current standards of the Joint Commission on the Accreditation of Healthcare Organizations for improving organizational performance.
Committee
Work
Design
The committee meets bimonthly or quarterly. Goals and activities are outlined at the beginning of the year, delegated to committee members, and evaluated at the end of the year. Most of the work is done outside the meetings by the members and others and then approved at the meetings. To minimize the impact on the productivity of the clinical staff, major responsibilities are delegated to the management members of the committee. For example, the committee chair, who is the clinical manager of the infusion program, personally tracks and analyzes vascular access device complications from infusion nurses’ “start-stop” reports.
Program
Support
The QM and information systems departments supplement the committee’s surveillance or data collection work. The QM department, for example, tracks employee blood exposure and purified protein derivative conversion rates. Data analysts help with databases, statistics, and reports. An effective management information system allows surveillance to be more automated, requires fewer staff for data collection, and provides displays and graphs that make analysis easier and, ultimately, less costly. HOME
CARE PROVIDER
155
MINDING
HERRICK AND LOOS
EVALUATION
AND RECOMMENDATIONS
There are several aduuntugesto an infection control system as described. An infection control committee brings a variety of staff with expertise to the program and distributes the work over a larger number of people. This eliminates the necessity to hire or designate one individual or department to carry out the infection control function (Table). The system also has potential disadvantages. A committee structure takes more coordination because a variety of departments and staff are involved. It may require additional time for the chairperson, who already has clinical management responsibilities. A committee approach can be more costly unless care is taken to ensure compact committee composition, effective meetings, and appropriate delegation of responsibilities. This is one approach to solving the difficult task of designing and implementing an infection control program in the home care setting that meets the challenges presented. It controls infections and improves practice. Although this approach works for us, each agency must consider the resources it has available, as well as the
OUR BUSINESS
required components, when designing an effective infection control program for home care. REFERENCES I. White MC, Smith W. Infection control in home care agencies. Am ] Infect Control 1993;21:146-50. 2. Council on Scientific Affairs, American Medical Association. Home care in the 1990s. JAMA 1990;263:1241-4. 3. White MC. Infections and infection risks in home care settings. Infect Control Hosp Epidemiol 1992;13:535-9. 4. Rosenheimer 1. Establishing a surveillance system for infections acquired in home healthcare. Home Healthcare Nurse 199S;l3(3):20-6. 5. Mayes J, Carter C, Adams JE. lnotropic therapy in the home care setting. J Intravenous Nurs 1995;18:301-6. 6. OSHA instruction CPL2 2.446. Washington, DC: Office of Health Compliance Assistance, Occupational Safety and Health Administration, 1990. 7. State of California. Blood borne pathogens. General Industry Safety Orders, Section 5193, Title 8, California Code of Regulations, January 1993. 8. Joint Commission on the Accreditation of Healthcare Organizations. Safety management and infection control. In: Standards for the accreditation of home care. Chicago: Joint Commission for the Accreditation of Healthcare Organizations, 1988:l I-2. 9. Presdorf RA. Infection control: regulatory impact on the home care setting. J Home Health Care Pratt 1993;6:60-8. Reprint no. 69/l/74419
What is it? This patient had a history of a “red varicose vein” and pain. This calf measured I inch larger than the other. Test your ubility to identify this corrdition. Answer
156
on page
HOME
15 8
CARE PROVIDER
MAY/JUNE
1996,
VOL.
1 NO. 3
Designing an Infection Control Program BY SYLVIA HERRICK, RN, MS, AND KAREN M. LOOS, BS, MPH
LACK OF RESEARCH AND SUPPORT Research data on infection control in the home care setting have always been very limited. Only recently have a few studies appeared in the literature.’ Those of us who have worked in home care for a number of years would agree that hospital infection control studies, research results, and surveillance practices have little relevance for home care. In addition, many freestanding home care agencies have limited infection control or epidemiology expertise within their staff or such staff available to them regularly, although hospital-based home care services are often an exception to this.
BUSINESS
RECENT CHANGES IN HEALTH CARE AND HOME CARE Added to this are the following challenges arising from changes in the delivery of health care and in the home care environment within the last few years.2 -% The drive to reduce the cost of bealtb cure in this country: Home care agencies are seeing more acutely ill ADDRESS FOR CORRESPONDENCE: Sylvia Herrick, RN, MS, or KarenM. Loos,BS, MPH Visiting Nurse Associationand Hospiceof Northern California 1900 PowellSt., Suite 300 Emeryville, CA94608
MAY/JUNE
1996,
VOL. 1 NO.
3
patients, especially those with a need for hightech services. These patients are more likely to require or recently to have had invasive procedures, exposing them to the increased possibility of infection. Also, the current managed care environment, with its greater emphasis on improved patient outcomes as well as cost containment, necessitates a very efficient infection control system Recent emerging ePidemiologicfactors in this couvrtvy: Within the last 10 years, there has been an increase in the number of patients with active tuberculosis, especially in urban areas where there are more immigrants and in the patient population with AIDS, who generally are more susceptible to tuberculosis. There has been a gradual increase in the numbers of patients with AIDS and other patients being treated at home and requiring high-tech procedures that previously were done in hospitals.5 Many of these procedures increase the potential for patient infections and for employee exposure to infections. Examples include aerosolized pentamidine treatments, blood product transfusions, chemotherapy administration, and bone marrow transplant follow-up. The increase in the numbers of drugresistant organisms complicates infection control procedures for all levels of the health care system, especially protocols for antibiotic use. Increased uwareness on the part of the public and home care workers regarding tbe spread of infections atid a concem HOME
CARE PROVIDER
153
MINDING
HERRICK AND LOOS
OUR BUSINESS
for protection from exposl*re: This has led to an increased public demand for infection surveillance in home care and for effective protocols to protect patients and staff from exposure.
PROLIFERATION
OF EXTERNAL
REGULATllONS Perhaps the greatest impact on current infection control systems is the proliferation of national and state regulations affecting home care, resulting in part from the factors just discussed. Just 7 or 8 years ago, there were almost no regulations regarding infection control in home care, and there was little surveillance and very little public concern.6.9 Since then, voluntary accrediting agencies, such as the Joint Commission on the Accreditation of Healthcare Organizations and the Community Health Accreditation Program, Inc., have set and upgraded standards for surveillance, prevention, and control of infections. The Occupational Safety and Health Administration (OSHA) also sets standards for the protection of workers, including those in the health care field. OSHA regulations include exposure control standards for tuberculosis, as well as the original control standards for blood borne pathogens. In addition, many states have laws to protect health care workers and the public from disease; for example, laws regulating medical waste management. These laws affect home care practice in the areas of providing care, educating patients, and transporting and tracking waste.
ESSENTIAL
PROGRAM
COMPONENTS
Designing an infection control system that adequately addresses these constraints and requirements is a challenge for today’s home care agency. A number of minimal components that address the current issues are required for home care infection control programs, and these are listed in the box.
DESCRIPTION
OF VNAHNC’S
PROGRAM
Visiting Nurse Association and Hospice of Northern California (VNAHNC) developed a home care infection control program, which evolved over the last 7 or 8 years and which is cost-effective, meets regulations, and focuses on maintenance or improvement in significant, high-risk areas. VNAHNC has grown in the last 7 years from 85,000 to more than 300,000 visits per year and includes multiple programs and delivery sites. This rapid growth contributed as much to the necessity for the infection control program as did the other factors already discussed. Though the program continues to evolve, a description of the structure and components of the current system follows.
Control
and Coordination
VNAHNC’s infection control program is directed and coordinated by a committee composed of management and staff. They report to an overall advisory and quality 154
HOME
CARE PROVIDER
management committee, the Professional and Quality Advisory Committee, which has community and provider as well as agency staff members and which ultimately reports to the board of trustees of VNAHNC.
Committee
Composition
The Infection Control Committee includes representatives from clinical operations, quality management (QM), education, clinical staff, and materials management. Members also represent the major programs in VNAHNC, including hospice, infusion therapy, perinatal/pediatric, and home care. The committee chairperson is a clinical manager who brings the necessary clinical and operational expertise and who communicates with the rest of the management team. Other staff attend as the agendas require. For example, a human resources department representative may participate in decisions regarding employee tuberculosis testing. The committee size ranges from five to eight members, and each member may represent more than one area; for example, clinical operations and home infusion.
Committee
Functions
The Infection Control Committee is responsible for the following: l Setting infection control program goals l Developing, regularly updating, and tracking adherence to exposure prevention and infection control policies and procedures MAY/JUNE
1996,
VOL.
t NO.3
MINDING
l
l
l l
OUR BUSINESS
Outlining and assisting in implementing mandated infection control-related education programs Designing and maintaining an infection surveillance system Analyzing and tracking infection patterns Recommending products that relate to infection control
Specific examples of how some of these functions are carried out are as follows: The committee annually revises VNAHNC’s Infection arrd ExposureControl Guidelinesand coordinates education for staff regarding these policies. l The group plans the required tuberculosis and blood borne pathogens educational updates. * Members developed a system to evaluate adherence to infection control policies and procedures in the field. Although the QM department collects data from checklists completed during supervisory visits, it is the committee that regularly reviews this summary for trends. l The committee developed an infection surveillance system to track infection patterns. The current system consists of an annual infection point prevalence study to obtain infection rates, and a few discrete projects focusing on high-risk areas to track for trends and possible improvement needs. These high-risk project areas include (I) employee purified protein derivative conversion rates, (2) employee blood and body fluid exposure rates, (3) vascular access device complications, and (4) vancomycin use patterns. These projects were chosen because they focus on some of the current concerns in infection control. They include hightech invasive care, increases in drug-resistant organl
MAY/JUNE
1996,
VOL.
1 NO. 3
HERRICK AND LOOS
isms, and employee concern for protection from exposure to disease. This “improvement project approach” fits the current standards of the Joint Commission on the Accreditation of Healthcare Organizations for improving organizational performance.
Committee
Work
Design
The committee meets bimonthly or quarterly. Goals and activities are outlined at the beginning of the year, delegated to committee members, and evaluated at the end of the year. Most of the work is done outside the meetings by the members and others and then approved at the meetings. To minimize the impact on the productivity of the clinical staff, major responsibilities are delegated to the management members of the committee. For example, the committee chair, who is the clinical manager of the infusion program, personally tracks and analyzes vascular access device complications from infusion nurses’ “start-stop” reports.
Program
Support
The QM and information systems departments supplement the committee’s surveillance or data collection work. The QM department, for example, tracks employee blood exposure and purified protein derivative conversion rates. Data analysts help with databases, statistics, and reports. An effective management information system allows surveillance to be more automated, requires fewer staff for data collection, and provides displays and graphs that make analysis easier and, ultimately, less costly. HOME
CARE PROVIDER
155
MINDING
HERRICK AND LOOS
EVALUATION
AND RECOMMENDATIONS
There are several aduuntugesto an infection control system as described. An infection control committee brings a variety of staff with expertise to the program and distributes the work over a larger number of people. This eliminates the necessity to hire or designate one individual or department to carry out the infection control function (Table). The system also has potential disadvantages. A committee structure takes more coordination because a variety of departments and staff are involved. It may require additional time for the chairperson, who already has clinical management responsibilities. A committee approach can be more costly unless care is taken to ensure compact committee composition, effective meetings, and appropriate delegation of responsibilities. This is one approach to solving the difficult task of designing and implementing an infection control program in the home care setting that meets the challenges presented. It controls infections and improves practice. Although this approach works for us, each agency must consider the resources it has available, as well as the
OUR BUSINESS
required components, when designing an effective infection control program for home care. REFERENCES I. White MC, Smith W. Infection control in home care agencies. Am ] Infect Control 1993;21:146-50. 2. Council on Scientific Affairs, American Medical Association. Home care in the 1990s. JAMA 1990;263:1241-4. 3. White MC. Infections and infection risks in home care settings. Infect Control Hosp Epidemiol 1992;13:535-9. 4. Rosenheimer 1. Establishing a surveillance system for infections acquired in home healthcare. Home Healthcare Nurse 199S;l3(3):20-6. 5. Mayes J, Carter C, Adams JE. lnotropic therapy in the home care setting. J Intravenous Nurs 1995;18:301-6. 6. OSHA instruction CPL2 2.446. Washington, DC: Office of Health Compliance Assistance, Occupational Safety and Health Administration, 1990. 7. State of California. Blood borne pathogens. General Industry Safety Orders, Section 5193, Title 8, California Code of Regulations, January 1993. 8. Joint Commission on the Accreditation of Healthcare Organizations. Safety management and infection control. In: Standards for the accreditation of home care. Chicago: Joint Commission for the Accreditation of Healthcare Organizations, 1988:l I-2. 9. Presdorf RA. Infection control: regulatory impact on the home care setting. J Home Health Care Pratt 1993;6:60-8. Reprint no. 69/l/74419
What is it? This patient had a history of a “red varicose vein” and pain. This calf measured I inch larger than the other. Test your ubility to identify this corrdition. Answer
156
on page
HOME
15 8
CARE PROVIDER
MAY/JUNE
1996,
VOL.
1 NO. 3