IC in Care Series: Home Healthcare


Quality improvement and infection prevention in home healthcare may be getting a boost from regulation proposed by the Centers for Medicare & Medicaid Services (CMS). Last July CMS announced a proposal to launch a new model designed to support greater quality of care among Medicare beneficiaries. The model is included in the CY 2016 Home Health Prospective Payment System proposed rule, which updates payments and requirements for home health agencies under the Medicare program. As proposed, the Home Health Value-Based Purchasing model would test whether incentives for better care can improve outcomes in the delivery of home health services.

By Kelly M. Pyrek

Editor's note: This article was part of a series published in the print issue of ICT in 2016 and may not reflect the most current CMS developments.

Quality improvement and infection prevention in home healthcare may be getting a boost from regulation proposed by the Centers for Medicare & Medicaid Services (CMS). Last July CMS announced a proposal to launch a new model designed to support greater quality of care among Medicare beneficiaries. The model is included in the CY 2016 Home Health Prospective Payment System proposed rule, which updates payments and requirements for home health agencies under the Medicare program. As proposed, the Home Health Value-Based Purchasing model would test whether incentives for better care can improve outcomes in the delivery of home health services.

“People want to be taken care of in their homes and communities whenever possible, and CMS aims to make sure that care in the home is supported by a value-based care delivery model that is consistent with the rest of the system," says acting CMS administrator Andy Slavitt. "The goal is that no matter where the care is delivered, it is supported by a payment system that rewards providers who deliver the highest quality outcomes.”

Authorized under the Affordable Care Act, the model leverages the successes of and lessons learned from other value-based purchasing programs and demonstrations – including the Hospital Value-Based Purchasing Program and the Home Health Pay-for-Performance and Nursing Home Value-Based Purchasing Demonstrations. The model would apply a payment reduction or increase to current Medicare-certified home health agency payments, depending on quality performance, for all agencies delivering services within nine randomly-selected states. Payment adjustments would be applied on an annual basis, beginning at 5 percent and increasing to 8 percent in later years of the initiative. The pro-posed model is designed so there is no selection bias, participants are representative of home health agencies nationally, and there is sufficient participation to generate meaningful results among all Medicare-certified home health agencies nationally.

"Currently we are operating with Medicare conditions of participation (CoPs) that were written back in the 1960s," says Mary McGoldrick, MS, RN, CRNI, a Georgia-based home care and hospice consultant. "There are currently proposed CoPs, and infection prevention; and control will have its own condition, with emphasis on prevention, control and education. Hopefully those will move forward sometime next year. That will help move home health agencies toward a more formalized infection control program."

In 2001, Rhinehart observed that "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. Valid and reliable definitions and methods for surveillance are needed. Prevention and control efforts are largely based upon acute-care practices, many of which may be 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."

Fifteen years later, home healthcare has evolved, but there is still room for improvement, says McGoldrick. "I have been in home care for more than 25 years and the field has become much more sophisticated over time. I think the home care nurses do a wonderful job with infection prevention and control but there is always the opportunity to grow and improve practices."   

Home healthcare is an expanding model of healthcare delivery. According to an April 2011 National Health Statistics Report from the U.S. Department of Health and Human Service (HHS), an estimated 1.45 million people received home healthcare in 2007. By 2050, HHS predicts that number will reach 27 million.

As Rhinehart (2001) notes, "Efforts to decrease length of hospital stay and shift care to ambulatory settings, as well as patient and family preference to receive care at home, have contributed to the substantial growth of home care in the past decade. As life expectancy in the U.S. population continues to increase and patients with chronic illnesses live longer, home care will continue to expand. Home care has also broadened in type and scope in the past decade. Most patients are elderly and have chronic conditions requiring skilled nurses and aides. High-tech home care is provided to patients of all ages and may include home infusion therapy, tracheotomy care and ventilator support, dialysis, and other highly invasive procedures. In addition, home-care nurses provide assessment, education, and support to post-acute-care patients who might have spent several additional days in the hospital but are now discharged to cut costs." Rhinehart (2001) adds, "As this segment continues to expand and services provided in the home increase, the infection control community must address the risks and needs of home care."

Those risks and needs are driven by the very nature of home healthcare, which can lack the regimented protocols and support systems of acute-care hospitals. Let's review some of these challenges:

Infection surveillance
Infection surveillance in the home healthcare arena is one of the biggest challenges. As Rhinehart (2001) attests, "Without valid data on the incidence of home care-acquired infection and analysis of risk factors, developing control efforts is difficult. Thus, initial resources must be directed toward developing measurement systems. Definitions and methods for the surveillance of nosocomial infection cannot be readily applied to home care. First, definitions, such as those developed by the Centers for Disease Control and Prevention's (CDC) National Nosocomial Infection Surveillance (NNIS) system rely heavily 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 with substantial reliance upon physical signs and symptoms"

Rhinehart (2001) explains further, "Definitions of home care-acquired infection developed for surveillance will need to rely more heavily on clinical signs and symptoms and tests that can be performed by the home-care nurse at the bedside. A scheme that includes probable home-care acquired infection (i.e., clinical signs and symptoms of pneumonia) as well as definite home-care acquired infection (i.e., confirmed by chest X-ray and sputum culture) may be considered. Once developed, definitions must be examined for validity, sensitivity and specificity. However, methods to identify patients at risk and apply the definitions are also critical. Surveillance methods routinely used in acute care, such as cultures and other laboratory tests, are not practical in home care so other sources of information and methods of screening must be developed. In addition, a system that relies on a designated person(s) to review medical records and assess patients for infection, such as infection control professionals do in hospitals, is impractical in home care because of the logistics of patients, staff and medical records."

McGoldrick emphasizes that there are currently no public reporting of infections requirements for home health agencies or hospices. "Any reporting that is done is based on the areas selected for surveillance activities by the agency, and they determine that through their risk assessments," she says. "So they conduct a risk assessment, determine what will be their targeted surveillance activities, and then they collect the data, report the data and analyze it. Some years ago the Missouri Alliance for Home Care established a surveillance database for home health agencies but this does not exist on a national basis. Some states have started to gather data, so that's a good start."

Rhinehart (2001) advocates for a two-tiered system that relies on home-care nurses to identify and report patients with clinical signs and symptoms of infection and on an infection control nurse to review evidence and ascribe a definition. "Screening criteria for home-care nurses would include fever, new antibiotic order, purulent drainage from a wound, change in color or odor of urine, change in consistency or color of sputum, respiratory rales and rhonchi, and increased serum leukocytes. Once made aware of these patients, a designated nurse can review the evidence (e.g., clinical signs and symptoms, available laboratory data, nursing and physician progress notes) and apply the definition of home-care acquired infection. This approach should enhance both sensitivity (more nurses observing and reporting patients with clinical signs and symptoms of infection) and specificity (one nurse applying the definition of infection). The use of a single infection control nurse should also improve the reliability of data."

Rhinehart (2001) adds that in order to achieve a system to measure and study the incidence and risks for home-care acquired infection, "infection control must develop valid definitions for home-care acquired infection and practical methods for surveillance. These definitions and methods must be developed through a broad, national effort that includes participation by home-care professionals as well as infection control practitioners. These professionals must take a very practical approach to this endeavor and may have to forego rigid application of epidemiologic techniques for a more suitable surveillance system. The Association for Professionals in Infection Control and Epidemiology (APIC) has recently published draft definitions for surveillance in home care. In parallel, home-care professionals must engage in learning the epidemiologic principles of surveillance systems and apply or adapt them as faithfully as possible."

According to APIC/HICPAC Surveillance Definitions for Home Health Care and Home Hospice Infections, "A healthcare associated infection (HAI) is an infection that develops in a patient who is cared for in any setting in which healthcare is delivered (e.g., acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter, home) and is related to receiving healthcare (i.e., was not incubating or present at the time healthcare was provided). In ambulatory and home settings, HAI applies to any infection that is associated with a medical or surgical intervention. Since the geographic location of infection acquisition is often uncertain, the infection is considered to be healthcare associated, rather than healthcare acquired. HAI criteria for home healthcare and home hospice are essential to the specific anatomical site definitions for HAI. Thus, home care and home hospice healthcare associated infections (HAIs) are those infections that were neither present nor incubating at the time of initiation of care in the patient’s place of residence. For those infections appearing in a patient within 48 hours of discharge from a healthcare facility, the infection(s) is reported back to the facility that discharged the patient prior to their home care services."

Rhinehart (2001) says that once consensus is reached on definitions and methods and the epidemiology of home-care acquired infections is better described, researchers can study specific risk factors for infection. But this comes at a price and Rhinehart (2001) acknowledges the need for resourcing and funding: "Home-care professionals need the assistance, support, and practical guidance of infection control professionals. Because of substantial financial challenges in home care, one nurse is often responsible for quality improvement, safety, risk management and infection control. These professionals can apply and manage surveillance systems but will need substantial guidance and support in developing them."

Occupationally acquired infections in home healthcare
Several years ago, Irena Kenneley, PhD, APRN-BC, CIC, assistant professor of nursing at the Frances Payne Bolton School of Nursing at Case Western Reserve University, observed that "The literature concerning home healthcare clinician/employee health, occupationally acquired infections, and protection of home healthcare clinicians from infectious disease is sparse," so she conducted a survey of home healthcare practices related to infection control. She wanted to determine the number of home healthcare clinicians diagnosed with an occupationally acquired infection caused by an MDRO, and among clinicians who have had these infections, whether the infection was transmitted to any of their own household members. She also desired to describe home healthcare policies and procedures related to infection prevention and control. A 22-item survey was sent to 3,800 home healthcare providers and also made available online. Survey respondents were female registered nurses (92.4%) between the ages of 51 and 60, and most participants had previous jobs in acute-care hospitals.

Among this sample of home healthcare clinicians, 5.91 percent reported that they were diagnosed with an occupationally acquired infection caused by an MDRO. Of the clinicians reporting infections, none reported that the infection was transmitted to any of their household members. Diagnosis was confirmed with microbiological culture in 71.4 percent of cases, and by physician assessment and other laboratory testing in the remaining 28.6 percent of cases. The majority of reported skin and soft tissue infections (SSTIs) were caused by MRSA at 76.2 percent. The second most frequent infection reported (33.3 percent) was gastrointestinal caused by Clostridium difficile. An unexpected result was 4 of the 21 clinicians reporting infections indicated they had both MRSA and C. difficile infection. Two respondents (9.5 percent) indicated they had sustained a needlestick injury and had acquired hepatitis B.

Kenneley (2012) notes that "Occupational transmission is usually associated with violation of one or more of three basic principles of IC: handwashing, vaccination of healthcare workers, and prompt placement of infectious patients into appropriate isolation. Similar research has not been conducted in home healthcare, however. It is not known how many home healthcare clinicians have acquired a healthcare-associated infection or whether these infections have been transmitted to their household members. Nor are there any studies that have examined timeli-ness of communication by the agency to the frontline clinician of their patient’s status regarding infection or colonization with an MDRO."

One patient-care item that is coming under scrutiny is the home healthcare nurse's bag. As Kenneley (2012) explains, "These are the containers that are carried from home to home, used by home healthcare nurses to transport blood pressure cuffs, gloves, supplies for venipuncture, and other items. Other clinicians may use similar bags to transport their discipline-specific supplies and paperwork. Home healthcare agencies' policies about nurses’ and other clinician bags vary widely, ranging from recommendations for clinicians not to bring supply bags into patient homes to recommendations that clinicians place a barrier (e.g., newspaper) beneath the supply bag in the patient homes to prevent contamination. One study (Bakunas- Kenneley & Madigan, 2009) generated evidence that nurses’ bags may serve as reservoirs for multiple-drug- resistant pathogens, suggesting a potential risk for indirect transmission of infection from one patient to another via a contaminated nurse's bag."

The home healthcare environment
Home healthcare workers are experiencing infections and injuries in part because they may not be as aware of the threats as acute-care personnel. 

As Kenneley (2012) explains, "Much of the IC research in home healthcare has focused on prevention of infections related to invasive patient devices (e.g., urinary catheters, intravenous catheters) or wound care, rather than the environment and patient-care equipment. One study (Zwanziger & Roper, 2002) examined the home healthcare environment. Investigators cultured 47 wound care supplies, including gauze, normal saline, and scissors and wound measuring guides, for home healthcare patients at baseline, day 7 and day 14. Pathogenic organisms were found on all 47 supplies at both day 7 and day 14, including S. aureus and Enterococcus, and there were more organisms at the 14-day time point. There was no determination of whether the organisms were drug-resistant. The researchers noted that the homes in their study ranged from 'filthy to clean' (Zwanziger & Roper, 2002). Anecdotal evidence from practicing home healthcare nurses indicates that some change how they manage patient-related supplies based on the perceived cleanliness of the home. However, a home that appears visually clean could be widely contaminated with pathogens, some of which may be drug-resistant."

McGoldrick confirms the uncontrolled home environment can present challenges. "Lack of control over the home environment and hygiene standards is a significant concern for home health agencies but one of the personality traits that makes a home health nurse successful is the ability to be a creative problem solver," she says. "They are prepared for opening that front door, walking through it and maybe not finding what they were expecting. There are all kinds of home environments and people who are sick may not be able to keep up with their home. So home care nurses are not unfamiliar with having to go into pest-filled environments and doing a good job in providing care, setting up a field that is clean and maintained while they are in the home, rendering care, performing hand hygiene as appropriate, protecting their supplies that are stored in the home or brought back and forth, and storing it in the home in a manner so that it is protected from pets, curious children or pests. They are used to that and they generally do a very nice job. It's not the most ideal situation, and it can be tough -- I give them credit for sometimes going into the most horrific home environments and they do that visit after visit and they do such a good job of providing care in borderline-safe environments, and they do the best job they can in trying to keep the patients safe at home." 

As Kenneley (2012) observes, "Current clinical practice guidelines set for acute and long-term care institutions have been used to bridge the gap to the home healthcare setting. The home healthcare setting differs from institutional healthcare settings significantly, however, and questions persist about the suitability of adapting institutional guidelines to home healthcare. For example, in the home healthcare setting, patients with open wounds or central venous catheters may undertake activities of daily living, such as bathing, exercising, gardening, and playing with pets."

Kenneley (2012) acknowledges that "Hospitals and long-term care institutions are controlled environments, compared to the uncontrolled patient home environment where home healthcare is delivered. However, the risk of transmission of infection associated with multiple patients receiving care from multiple providers in one area of an institutional setting is not present in the home healthcare setting. There are growing concerns regarding the spread of multiple-drug-resistant organisms (MDROs), such as methicillin-resistant Staphylococcus aureus (MRSA), which is not only healthcare-acquired, but has become community-acquired as well. It is projected that home healthcare will be the focus of patient care activities should such an event occur. This issue is highly relevant for home healthcare; therefore, an evidence base for prevention and control of MDRO is needed. There is little research literature in this area of home healthcare."

Infection prevention practices
How home healthcare is delivered can have an impact on infection control practices, with the availability of a dedicated infection preventionist. There are numerous home health agencies, but hospitals and healthcare systems also can provide these services. McGoldrick says that typically hospitals have a department that functions as a home health agency or hospice that provides care in the home, and those individuals are employees of the hospital. "Sometimes hospitals enter into agreements with other home care providers in a preferred provider arrangement. Otherwise, hospitals will, at the time of discharge, give patients the choice of which home health agency might serve them best in their area, and if they don't have a preference, the hospital will make a referral, usually on a rotating basis with the local home health agencies in the area."

McGoldrick continues, "One of the benefits that the agencies have if they are structured under a health system or hospital is that they have access to a go-to person, the infection preventionist that is affiliated with the hospital. I would say that home health agencies and hospices, overall, do a uniformly good job of preventing infections the best they can but it's a definite advantage to have that support if there are infection control-related questions."

"Typically home health nurses do a very nice job in observing infection prevention measures, but one of the things that is really unique to home care is the intermittent nature of the healthcare delivery," McGoldrick adds. "The nurse or other care provider visits the home several times a week, depending on what the patient's care needs are. The nurses are teaching both the patient and the family members how to per-haps perform wound care, or how manage a medical device such as a Foley catheter. So it does raise the stakes for infection -- just as we have breaches in infection control that lead to infections among hospital staff, there can be breaches in protocol among patients and family members providing care. Or patients are going to other ambulatory care facilities such as infusion centers and having their central line accessed for blood draws or administering chemo, or they might be going to a wound care clinic. It may not be just the home care staff that could be interacting with the patient, so when a patient does develop an infection under the home-care watch, there may be multiple causative agents. That's one of the challenges from a surveillance standpoint -- correctly identifying home care-onset infection. What the agency does is drill down to deter-mine why this patient developed an infection while receiving home-care services -- was there anything the home-care staff or the family members did, or could other people or organizations have contributed to this infection?"

The acuity level of home healthcare delivery is rising, with more complex devices and procedures being performed in the home. As Rhinehart (2001) notes, "Even without reliable surveillance data, we know that infection prevention and control in home care is quite different from that in acute care. In acute-care, a patient's risk for nosocomial infection is related not only to the severity of illness and exposure to invasive interventions and devices but also to environmental risks, including exposure to other patients and inanimate reservoirs of nosocomial pathogens. The home-care patient may have less clinical acuity (i.e., intensity or degree of care needed) but may have substantial host risk factors, including advanced age, chronic illness, or immunosuppression. Much of home care is provided by family members in a setting that is much less structured and controlled than the hospital environment. Plumbing, sanitation, and ventilation may be poor or absent. Nonetheless, basic principles of prevention and control can be adapted and applied with large doses of realistic risk assessment and common sense."

"More patients are coming home with more devices, more drug-resistant organisms, so it's critical that the nurses be very careful in how they manage their equipment and supplies, and that they are not bringing those organisms  into another patient's home that may never have been exposed to them," McGoldrick says.

She emphasizes the appropriate utilization of standard precautions. "The focus on transmission-based precautions is very important," McGoldrick says. "Typically you are made aware by the referral source of a patient who has a drug-resistant organism or some kind of infectious condition that does require some kind of additional transmission-based precautions in addition to standard precautions. Droplet and con-tact precautions can be fully implemented in the home setting. The patient and the environment is assessed to see if there are any precautions that need to be implemented -- the nurses know what they need to do, but to make sure if there are additional levels of precautions, that must also be communicated to other people -- the pharmacy delivery driver who might put meds in the fridge, or the durable medical equipment representative that will do an oxygen concentrator check -- in order to prevent transmission to them and to others."

As Rhinehart (2012) notes, "In most cases, the use of gowns, gloves, and masks in the care of homebound patients is recommended to protect the healthcare provider, not the patient. In addition to standard precautions, care givers in the home may need to use masks only when caring for patients with pulmonary tuberculosis. The exception to this rule may be the home-care patient who is colonized or infected with multidrug-resistant organisms. Although these organisms are not known to be a risk to providers, they may be transmitted to other home-care patients through inanimate objects or hands. Thus, home-care patients known to have a multidrug-resistant organism should be cared for through use of appropriate barriers. Reusable equipment such as stethoscopes and blood pressure cuffs should remain in the home. If practical, such patients should be seen as the last appointment of the day. If this is not possible, visits should be scheduled to avoid seeing patients at risk, such as those requiring wound care, after seeing a patient with multidrug-resistant organisms."

That said, Rhinehart (2001) challenges the overutilization of precautions: "Because written resources for home-care practice are lacking, many home-care providers have adopted unnecessary infection control practices to reduce risk for patients, including the ritual of nursing bag technique (i.e., placing a newspaper under the nursing bag), policies that require the routine disinfection of noncritical devices (e.g., stethoscopes and blood pressure cuffs) after every use, and procedures that require handwashing based on seemingly arbitrary criteria (e.g., upon entering the home). Some of these practices are not only unnecessary but also costly (e.g., routine changing of urinary drainage bags every 30 days). Patient-care practices to reduce the risk for home-care acquired infection must be based on the basic science embodied in the chain of infection model. Actual risk and appropriate prevention and control strategies must be incorporated in recommendations for policy and procedure. Using this simple approach to determine actual risk and implement the appropriate prevention and control strategies will lead to more reasonable and less ritualistic practices for patient care and use of precautions to prevent the spread of infections to others. Infection control professionals should approach their responsibility to guide home-care providers by first addressing educational needs. 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."

McGoldrick says an advantage to home healthcare is working with just one patient and one set of equipment at a time. The same cautions in acute-care should be exercised, however, to prevent transmission. For example, McGoldrick says intermediate-level disinfection with a hospital-grade disinfectant is appropriate for telemonitoring equipment or infusion pumps delivered to the home that may have been used by other patients. "Other equipment such as blood pressure cuffs, stethoscopes or pulse oximeters that are in nurses' bags that are potentially shared during checks of vital signs, should low-level disinfected before placed back into the nurse's bag," McGoldrick says. "Assuming the patient doesn't have a drug-resistant organism, the nurse would follow the home health agency's policy, which according to the CDC, means that it needs to be cleaned on a regular basis and when visibly soiled. I suggest people move toward this practice while they are in the home, that be-fore it goes back into the bag, just do a low-level disinfection to reduce the bioburden of organisms.  Typically people wipe down their stethoscope with an alcohol prep pad."

McGoldrick acknowledges the variability in practice and adds, "Personally I suggest nurses wipe down the equipment each time to prevent the transfer of organisms from home to home to home. It's not necessarily evidence-based but I think it's best to err on the side of being cautious. Keep the bar high, and be aware of where the equipment is placed during use. And of course nurses must follow good hand hygiene practices and the indications for when it should be performed, following either the WHO or CDC guidelines."

Kenneley (2012) advises that "Ongoing education of clinicians, patients, and caregivers must include product use and appropriate disinfection practices for linens, household supplies, and the home environment. Education should focus particularly on cleaning and disinfection of frequently touched surfaces such as bedside commodes, bedside tables, doorknobs, and equipment in the immediate vicinity of the patient. Environmental disinfection should be a priority practice for patients on contact precautions. Noncritical medical equipment and other patient care items for individual patients known to be infected or colonized with an MDRO should be left in the home. These are called dedicated medical items, and may include stethoscope, blood pressure cuff, and wound care supplies. The amount of items brought into the home should be limited. If non-critical items cannot remain in the home, clean and disinfect items before removing them from the home, using a low-to-intermediate level disinfectant, or place reusable items in a plastic bag for transport to another site for subsequent cleaning and disinfection."

Rhinehart (2001) says that infection prevention strategies in home care should focus on home infusion therapy, urinary tract care, respiratory care, wound care, and enteral therapy: "Most recommended practices on intravenous therapy do not require adaptation for the home. How-ever, in care involving other sites, the risk may be lower, allowing for adaptation of practices designed for hospitalized patients. For example, use of indwelling urinary catheters creates an inherent risk for infection. In the hospital, considerable efforts are exerted to maintain an intact, closed urinary drainage system; however, in home care the system is frequently interrupted when an ambulatory patient uses a leg bag. Drain-age bags may also be disinfected in the home, a procedure rarely (if ever) seen in a hospital. Guidance provided to accomplish this procedure is empiric. Similarly, empiric approaches have been developed for home wound care. Surgical site infection should rarely, if ever, be a home-care acquired infection if the wound is primarily closed and no drains are left in place. However, if a surgical patient is sent home with drains, a surgical site infection may develop, and wound-care procedures must address this risk. More frequently, home-care patients have other types of wounds, such as stasis ulcers and pressure sores, which are commonly colonized with Gram-negative flora and may become infected with the patient's own organisms. Again, procedures for care of these wounds must be based on the genuine potential for contamination and infection. Many home-care patients receive enteral therapy, introducing the risk for gastrointestinal infection. Again, to reduce this risk, focus must be placed on refrigeration of the enteral feeding and meticulous care of kitchen appliances and tools, such as blenders, used in its preparation. Cleaning blender parts, measuring cups, and spoons in a dishwasher after use is probably sufficient; sterilizing them is probably not necessary."

Infection control policies
So what guidelines are being followed in home healthcare? Kenneley (2012) notes that "Home healthcare agencies (HHAs) develop policies and procedures for infection prevention and control by adapting existing guidelines from the Association for Professionals in Infection Control (APIC), the Centers for Disease Control and Prevention (CDC) Program Healthcare Infection Control Practices Advisory Committee (CDC HICPAC), or the U.S. Department of Health and Human Services (DHHS), among others. Agencies may also follow recommendations for home healthcare developed by infection control and clinical professionals. Adaptation of institutional guidelines to the home healthcare setting can be challenging, however, so substantial variation in practice exists."

However, Kenneley's 2012 survey revealed that a little more than half of clinicians reported that their agency did not have a written policy regarding IC precautions for care of patients colonized with MDRO, while slightly more than two-thirds reported that their agency did have a written policy regarding IC procedures for patients diagnosed with MDRO infection. About two-thirds of clinicians reported their agency did have a written policy for use of dedicated equipment for patients with diagnosed MDRO infection. The types of equipment that most frequently remain in the patient home include stethoscope and blood pressure cuff. More than three-fourths of clinicians reported that their agency did have a written policy regarding patient and family teaching for infection prevention and control. Only about one-half of clinicians reported they did not take their nurses’ bag into the homes of patients with diagnosed MDRO infection, whereas the other half reported that they did this at least\ sometimes. More than three-quarters of participants indicated they do not have a full-time infection preventionist (IP) at their agencies, and for those that do employ an IP, one-third have other jobs and duties within the agency.

Kenneley (2012) asserts that "Reducing the incidence of healthcare-associated infections and protecting patients, clinicians, and caregivers will require a collaborative response that crosses all settings where healthcare is delivered. This response must include emphasis to improve communication during transitions among healthcare settings when MDROs are involved. Standardization of infection prevention and control practices with emphasis on the flexibility necessary in the home healthcare setting while maintaining proper technique is needed. Infection prevention and control educational programs for frontline clinicians need to be provided on an ongoing basis. These educated frontline clinicians can then teach their patients/families about standard precautions, handwashing and basic infection prevention, teaching them what they need to know when no other help is available."

Kenneley (2012) says that the wide variation of infection prevention practices reflected in her study shows there is disagreement among home healthcare professionals about the environment of care and patient/employee safety practices: "Contact isolation is not required in some of the participants’ agencies, but this issue has immense public health implications underscoring the need for standardization of infection prevention practices. Occupationally acquired infections cause considerable illness and occasional deaths among healthcare professionals. Further studies in home healthcare are needed to enhance compliance with established IC practices."

McGoldrick and Rhinehart (2000) agree: "Home care and hospice nurses have always adapted and applied infection prevention and control strategies to the best of their abilities with few, if any, external resources. Although home care and hospice nurses are knowledgeable in the basics of infection control, they often face a significant challenge when adapting acute care practice to the home care setting. This adaptation has resulted in a wide variation of practices and methods for patient care (e.g., cleaning and disinfecting equipment, using clean versus sterile technique), as well as the development of many ritualistic, arbitrary practices that have been codified in the home care and hospice organization’s policies and procedures."

Kenneley (2012) recommends the following for shaping home healthcare practice in the context of infection prevention: Standardization of infection prevention and control, ongoing education about infection prevention and control, addressing the home environment and cleaning, national benchmarking, and antibiotic stewardship. As for the future of infection control in home healthcare, Rhinehart (2012) notes, "The next several years will be critical for developing surveillance systems for home care. Additional studies and reports are needed to improve knowledge of the risk factors for home-care acquired infections. We also need to study the effects of the current empiric practices for preventing such infections. Hospital-based infection control professionals must support and guide their home-care colleagues to develop an evidence-based approach to infection control in home care. A scientific approach will help identify valid risks and successful risk-reduction strategies, as well as improve the quality of care and preserve resources."


Kenneley I. Infection Control in Home Healthcare: An Exploratory Study of Issues for Patients and Providers. Home Healthcare Nurse. Vol. 30, No. 4. April 2012.

McGoldrick M and Rhinehart E. Improving Infection Control in Home Care: From Ritual to Science-Based Practice. Home Healthcare Nurse. Vol. 18, No. 2. February 2000.

Rhinehart E. Infection Control in Home Care. Emerg Infect Dis. Theme Issue: 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Vol. 7, No. 2. April 2001.


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