27Bloodstream infections (BSIs) associated with vascular access devices (VADs) are preventable. For acute care hospitals, central line–associated BSI (CLABSI) rates are publicly reported on the Medicare.gov website (“hospital compare”) and any VAD-related BSI is considered a preventable event with treatment not reimbursable under Medicare. Although the same reporting and reimbursement constraints do not currently apply in home care, prevention of infusion-related complications, including infection, is a growing concern. For home care agencies certified by the Centers for Medicare and Medicaid (CMS), acute care hospitalizations for home care patients are publicly reported (“home care compare”). Data from the Medicare-required Outcome and Assessment Information Set (OASIS) were used to describe rates of hospitalization and emergency care use caused by infection based on a 20% random sampling of 2010 OASIS data (Shang, Larson, Liu, & Stone, 2015). Of 36,330 unplanned hospitalizations based on a sample of 199,462 patients representing 8,200 home care agencies, 17% (n = 1,587) of hospitalizations were due to infections with 0.3% (n = 105) caused by intravenous (IV) catheter-related infection. Significant characteristics associated with infections included younger age, more likely men, more likely White, had cancer or renal disease, and more likely to be receiving IV therapy or parenteral nutrition (PN). A limitation of OASIS data is that the home care clinician completes the reason for hospitalization based on the best information available at the time of hospital transfer. Nevertheless, infections occur in the home care setting, are a serious problem, and considerable variation in infection control policies and practices exists (Shang et al., 2015).
After reading this chapter, the reader will be able to:
■ 28Discuss the importance of identifying and reporting infections in home care
■ Describe the pathogenesis of a catheter-related BSI
■ Apply standard and transmission-based precautions in home care
■ Identify specific strategies aimed at preventing infections during infusion therapy
DEFINING INFECTIONS AND CLARIFYING COMMON TERMINOLOGY
The terms catheter-related bloodstream infection (CR-BSI) and central line–associated bloodstream infection (CLABSI) are often used interchangeably, but they have different meanings. CR-BSI is a clinical diagnostic definition that requires specific laboratory testing that identifies the catheter as the source of the BSI; removal of the VAD and culturing of the catheter tip are recommended as part of the diagnostic process, from which a treatment plan can be developed. CLABSI is a surveillance definition that seeks to compare rates of infection within a population, and is defined as a primary BSI (i.e., no apparent infection at another site) that develops in a patient with a central line in place within the 48-hour period before onset of the BSI that is not related to another site; blood cultures are required (Association of Professionals in Infection Control and Epidemiology [APIC], 2015; O’Grady et al., 2011). Note that there are home care infection definitions as established by APIC and the Centers for Disease Control and Prevention’s (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC; 2008), but they have not been widely applied. Home care and home hospice health care–associated infections (HAIs) include infections that were neither present nor incubating at the time of initiation of care in the patient’s place of residence. Should the infection appear in a patient within 48 hours of discharge from a health care facility, the infection(s) is reported back to the facility that discharged the patient prior to his or her home care services, and thus not reported as a home care–associated infection (APIC and HICPAC, 2008).
29INFECTION SURVEILLANCE IN HOME CARE
In general, the risk of infection for patients living at home with VADs or other access devices is accepted to be low. A major advantage to home infusion therapy is that the risk of transmission associated with multiple patients and multiple providers in an institution is eliminated in the home setting. Some patients, however, may face increased risk for infection due to such factors as being immunocompromised (e.g., pediatric oncology patients), having a multilumen VAD, or receiving a higher risk infusion such as PN (Buchman, Opilla, Kwasny, Diamantidis, & Okamoto, 2014; Gorski et al., 2016; Keller et al., 2016; Rinke, Milstone, et al., 2013; Shang, Ma, Poghosyan, Dowding, & Stone, 2014). Patient and caregiver self-administration of infusions may pose a potential risk; however, this may also be an advantage for the many patients who take their role in performing their infusions and VAD care very seriously. Environmental factors have been hypothesized as risk factors for infections. Common exposures including well water, cooking with raw meat, soil exposure through yard work, or having a pet in the home were not found to increase the risk of central VAD (CVAD) complications in a recent prospective study (Keller et al., 2016).
In an 11-year surveillance study from the University of North Carolina Health Care System, the overall rate of home care CLABSI was very low at 0.22 infections per 1,000 device days representing nine infections over 40,763 device days (Weber, Brown, Huslage, Sickber-Bennett, & Rutala, 2009). The cases were identified by home care nurses and reviewed by infection control staff using CDC definitions of nosocomial infections. Ask yourself the following questions in relation to your home care organization:
■ Do you know what the CLABSI rate is in your home care organization?
■ Do you report possible catheter-related infections as part of your agency’s performance improvement program?
Unlike acute care hospitals, in home care the reality is that infection surveillance is not consistently performed and infection rates are not consistently measured or not measured consistently with standardized surveillance definitions. Challenges include ensuring a reliable reporting system, calculating VAD days, and validating infections. In an investigation of home care agency CLABSI definitions and prevention policies in pediatric home care, only 25% (14/57) 30of surveyed agencies knew their overall CLABSI rate (mean 0.40 CLABSIs per 1,000 central line days; Rinke, Bundy, et al., 2013).
Despite the challenges, without identifying and tracking infections, it is difficult to identify areas for performance improvement. Home care agencies must strive to do better. Helpful strategies and tools for data collection are published in a “toolkit” available online (United Hospital Fund, 2016). When an agency does identify infection rates, opportunities for improvement are identified. Consider the following example:
Infections in patients with PICCs [peripherally inserted central catheters] were reduced by 46% in patients receiving home infusions (0.963 to 0.52 infections per 1000 central line days). A lack of standardized care protocols was identified as a key problem and interventions included standardizing home health central line orders (NC [needleless connector] changing and disinfection, flushing, blood draws, site care), development of checklists for central line care and flushing, and nursing education. (Baumgarten et al., 2013)
Fast Facts in a Nutshell
VAD-related infections that occur in a home care patient must be considered potentially preventable. Any infection that occurs should result in a case review by the clinicians involved in the case. Areas to discuss include patient risk factors (e.g., high-risk infusions such as PN, immunocompromised status, and type of VAD including number of lumens), environmental factors (e.g., cleanliness of home and pets), nursing adherence to infection prevention practices, and patient teaching strategies and evaluation of their effectiveness. Although it is easy to place “blame” on a patient and/or the home situation, a critical and objective look at agency practices, in hindsight, may uncover opportunities for improvement and risk reduction.
PATHOGENESIS OF CR-BSIs
Microorganisms gain access to the vascular system, potentially leading to a BSI via four main routes: extraluminal, intraluminal, 31hematogenous seeding, and through contaminated infusate (APIC, 2015; O’Grady et al., 2011; Safdar, Maki, & Mermel, 2014; see Figure 3.1).
Figure 3.1 Sources of IV-related infections. Source: Safdar et al. (2014). Used with permission.
HCW, health care worker.
Extraluminal
Organisms at the insertion site or on a contaminated catheter migrate into the catheter tract and along the external catheter surface, thus gaining access to vascular system.
■ Potential sources of microorganisms include the patient’s skin, health care worker (HCW)/caregiver hands, or contaminated disinfectant.
■ The extraluminal source for infection is the predominant cause in the short term (e.g., within the first 2 weeks after VAD insertion; Mermel, 2011).
Intraluminal
Direct contamination of the catheter or catheter hub occurs, giving microorganisms access through the internal lumen of the catheter.
■ 32Potential sources of microorganisms include the patient’s skin and HCW/caregiver hands.
■ Risk is present every time the catheter is accessed (e.g., during medication or fluid administration, catheter flushing, and changing of the needleless connector [NC] or IV tubing).
■ The intraluminal source of infection is the predominant cause associated with prolonged VAD dwell time as the number of catheter manipulations and accesses increases (Mermel, 2011).
Hematogenous
Organisms are carried to the catheter from a remote source of infection present in the patient. This is considered a rare cause of infection.
Contaminated Infusate
■ Intrinsic contamination: Infusates can become contaminated during the manufacturing process. This is a rare cause of infection; however, it can cause epidemic device-related infections because of the large numbers of patients in multiple settings who may be affected.
■ Extrinsic contamination: Risk is present if infusates are not properly handled (e.g., improper refrigeration, failure to adhere to aseptic technique during solution preparation).
STRATEGIES TO REDUCE THE RISK FOR INFECTION
Always Apply Standard and Transmission-Based Precautions
Standard precautions are required in the care of all patients regardless of their infection status to protect the clinician as well as the patient. Standard precautions are based on the principle that all blood, body fluids, secretions and excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are intended to protect the health care provider as well as the patient from health care–associated transmission of infectious agents (Siegel, Rhinehart, Jackson, & Chiarello, 2007). Standard precautions include the following infection prevention practices: hand hygiene; personal protective equipment (PPE), such as gloves, gowns, masks, eye protection, or face shields; and safe injection practices.
33Fast Facts in a Nutshell
Nurses should have PPE readily available during the course of making home visits. Minimally, this should include one full gown, one set of eye protection, nonsterile gloves, one face mask, and if applicable, one N95 respirator, and one resuscitation mask (McGoldrick, 2016).
Transmission-based precautions are additional precautions based on the known or suspected infectious state of the patient and the possible routes of transmission. There are exceptions to application of transmission-based precautions, particularly in the home setting, where the risk of transmission is not well defined, an isolation room is not possible, and family members already exposed to diseases generally do not wear masks. Transmission-based precautions must be adapted and applied as appropriate in home care. There are three categories of transmission-based precautions (Siegel et al., 2007):
■ Airborne precautions require special air handling and ventilation to prevent the spread of organisms. In the home setting, control of air handling is not possible. Clinicians caring for the patient on airborne precautions wear a mask or respirator (HEPA or N95 respirators), which is donned when entering the home setting. Although airborne precautions are not a common home infusion therapy situation, an example would be the patient with tuberculosis who is multidrug resistant and requires antimicrobial infusion therapy.
■ Droplet precautions require the use of mucous membrane protection (eye protection and masks) to prevent infectious organisms from contacting the conjunctivae or mucous membranes of the nose or mouth. Examples of infections are mumps, rubella, influenza, adenovirus, rhinovirus, and pertussis.
■ Contact precautions require the use of gloves and gowns when direct skin-to-skin contact or contact with a contaminated environment is anticipated. Application of contact precautions is not uncommon in home care because there are many patients with infections such as Clostridium difficile and infections due to multidrug resistant organisms (MDROs) such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).
34Fast Facts in a Nutshell
