Efforts Lag in Home Care Infection Surveillance and Prevention

Vol. 13 •Issue 2 • Page 28
Home Pathways

Efforts Lag in Home Care Infection Surveillance and Prevention

Although home care has expanded in scope and intensity in the United States in the past decade, infection surveillance, prevention and control efforts have lagged behind.

Infection control in home care settings poses several unique challenges, including lack of nationally accepted standard definitions of infection and methods of data collection, loss of patient follow-up, lack of trained infection control respiratory therapists in home care settings, difficulty capturing clinical and laboratory data, and problems obtaining numerator and denominator data for calculation of infection rates.

Prevention and control efforts are largely based upon acute-care practices, many of which are unnecessary, impractical and expensive in a home setting. Infectious disease control principles should form the basis of training home care providers to assess infection risk and develop prevention strategies.

Also, collaboration between home health care agencies, state and federal health agencies, private industry, and national or managed care organizations is essential to making a surveillance system feasible and functional.1

JCAHO’s Role

The Joint Commission on Accreditation of Healthcare Organizations is making strides to improve the system, as its executive committee of the board of commissioners recently met with home care representatives to address the issue of infection.

A major point of discussion was related to providing care in a patient’s home, which differs from other health care settings in many ways, including the lack of control over the patient’s environment and the little direction in dealing with infection control.

JCAHO, along with experts from the home care industry, have worked toward developing national standards that clearly define quality home care services, whether provided by RTs employed by DME/HME companies or home health care organizations.

JCAHO also recently revised its infection control standards for the prevention and control of health care-associated infections. All JCAHO-accredited organizations are expected to incorporate an infection control program as a major component of their safety and performance improvement programs.

In addition, each organization must conduct an ongoing assessment to identify risks for the acquisition and transmission of infectious agents. This includes surveillance, collecting data, and implementing infection prevention and control processes; education and collaboration with leaders across the organization on the design and implementation of the infection control program; integrating efforts with health care and community leaders; and planning for infections that may potentially overwhelm resources.

National Patient Safety Goals

In a presentation by the president of JCAHO in November, Dennis S. O’Leary, MD, stated, “The Centers for Disease Control and Prevention estimated that there are at least 2 million health care-associated infections each year. Of these, 90,000 people die and, most importantly, a third of these deaths are probably preventable.”

JCAHO’s concerns regarding infection control led it to convene the expert panel to conduct an evaluation of its infection control standards, and concurrently, the CDC issued the new hand-washing guidelines. JCAHO publicly urged its accredited organizations to comply with the new guidelines.

And this past summer, the JCAHO board of commissioners added a seventh national patient safety goal to its already-existing six 2003 goals. Specifically, as of Jan. 1, 2005, all accredited organizations must be in compliance with the hand-washing guidelines established by the CDC.

This includes the need for communication and collaboration between leaders of health care organizations, local health departments and other community agencies.

Also, the importance of surveillance is supplemented by an emphasis on identification and intervention.

In addition, the standards are linked to performance improvement requirements, and the expectation is that JCAHO surveyors will review whether data and analyses exist along with action plans, and measurable results.

Dr. O’Leary notes that the revised standards are effective on Jan. 1, 2005, however they’ll be reviewed during the course of the 2004 random unannounced surveys.

Trends that Need Attention

The boom in high-tech home care has reached patients of all ages and helps to reduce the acute care length of stay, thus cutting costs. But as a result, the risk of infection at home has increased.

The available literature regarding infection control and current definitions and methods for the surveillance of institutional infection can’t be applied to home care.

The CDC’s National Nosocomial Infection Surveillance system relies on laboratory data, including cultures and serologic tests.

In home care, the diagnosis of infection for clinical purposes is frequently made on an empiric basis that relies on signs and symptoms and the assessment skills of the home care provider.2

Unfortunately, the current reimbursement system doesn’t support the use of some providers in the home, particularly RTs, and it doesn’t cover the costs of laboratory services.

A more suitable approach is a system that relies on home care providers (RTs) to identify and report patients with clinical signs and symptoms and facilitate the assessment from a physician and laboratory tests via an office visit. However, in the current environment of reimbursement cuts, it’s unlikely that this type of system will come to fruition.

In order to achieve a quantifiable system to measure and study the incidence and risks for home care-acquired infection, infection control must develop valid definitions for home care.3

When a clear delineation is reached on definitions and methods, and we describe the epidemiology of home care-acquired infections, the specific risk factors for infection then can be assessed to develop a framework to establish consistent standards.

Home care professionals need the assistance, support and practical guidance of infection control professionals.

Infection Control Principles

Family members providing home care is another growing trend, and many providers have adopted unnecessary infection control practices to reduce risk, and these principles are even more foreign to a lay caregiver.

Knowledge of infection control principles enables home care providers to develop their own approaches to patient care and make decisions about infection risk and its reduction. Thus, education on the risks is more appropriate particularly when family members are caregivers.4

Procedures must be practical, with guidance to use containers for sputum to avoid contamination of fluids (e.g., proper handling of the cap, storage away from children and pets).4

The rationale and strategy for use of precautions in home care differ substantially from those applied in hospitals.

In most cases, the use of gowns, gloves and masks in the care of homebound patients is recommended to protect the health care provider, not the patient. In addition to standard precautions, caregivers in the home may need to use masks only when caring for patients with pulmonary tuberculosis.5

Uncertain Future

Although currently there are no clear standards established by the CDC for home care, the next few years are critical for developing surveillance systems for the field. Additional studies and reports are needed to improve knowledge of the risk factors for home care-acquired infections. n


1. Rhinehart E. Infection control in home care. Emerg Infect Dis. 2001;.7(2):208-11.

2. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control. 1988;16(3):128-40.

3. Friedman MM, Rhinehart E. Putting infection controls principles into practice in home care. Nurs Clin North Am. 1999:34(2):463-82.

4. Goldberg P, Lange M. Development of infection surveillance projects for home healthcare. Home Care Manag. 1997;1(2):1,4-9.

5. Friedman MM. Designing an infection controls to meet JCAHO standards. Caring. 1996;15(7):18-25.

Pertelle is acting director of respiratory at Apria Healthcare, Lake Forrest, Calif.