Controlling HAIs in nursing homes a daunting task

Pennsylvania is the first and only state to mandate health care-associated infections reporting in all nursing home facilities.

The acuity of infections in nursing homes has steadily increased in recent years. Almost as many health care-associated infections occur annually in long-term care facilities as in hospitals in the United States, according to recent findings published in Infection Control and Hospital Epidemiology.

“The last two decades have seen increased recognition of the problem of infections in [long-term care facilities], with subsequent widespread development of [long-term care facilities] infection control programs and definition of the role of the [infection control practitioner] in [long-term care facilities],” Philip W. Smith, MD, professor of infectious diseases at the University of Nebraska Medical Center, and colleagues wrote in the study.

However, it is difficult to apply the practice of infection control in the hospital environment to the realities and practicalities of infection control in long-term care facilities, “especially when dealing with residents who are colonized or infected with health care-associated infections (HAIs) such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci or resistant gram-negative bacilli,” said Donald Kaye, MD, Infectious Disease News Editorial Board member.

Nursing homes do not have the resources that hospitals do for infection control, and it is unreasonable to have such expectations, according to Kaye.

Bill passed in 2007

In 2007, Pennsylvania became the first state to initiate infection prevention strategies in nursing homes by incorporating education and training needed to implement a mandatory HAI reporting system in all nursing homes across the state.

Phenelle Segal, RN, CIC, representing The Pennsylvania Patient Safety Authority (PSA), presented findings from the first year of mandatory reporting in Pennsylvania nursing homes during the 38th Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology.

In July 2007, Gov. Ed Rendell of Pennsylvania signed Senate Bill 968, known as Act 52 of 2007, into legislation. This required mandatory reporting of all HAIs in both hospitalized patients and residents of nursing homes, with specific reporting requirements for both entities.

All Pennsylvania nursing homes began reporting HAIs to the PSA in June 2009 through a secure, Web-based system known as the Pennsylvania Patient Safety Reporting System (PA-PSRS). The system is based on a list of reportable infections and criteria developed by PSA and Department of Health, with guidance from the HAI Advisory Panel.

According to Segal, PSA was responsible for developing the program and providing the tools, training and ongoing comprehensive education for more than 700 nursing homes in Pennsylvania.

Legislation brings change

Segal said Act 52 of 2007 has represented a positive change for nursing homes. Nursing homes in Pennsylvania now have a standardized method for identifying infections, collaboration at a statewide level and effective networking among facilities.

The results of the first year are indicative of the potential benefits of HAI reporting. Based on the first full year of data collectionevaluated in the 2010 annual report, about 714 nursing homes reported 27,869 HAI events to the PA-PSRS in 2010. Respiratory tract infections accounted for most infections (n=9,929); followed by gastrointestinal infections (n=8,495); skin and soft tissue infections (n=5,214); and urinary tract infections (UTIs; n=3,883).

Compared with 2009 data, nursing homes reported fewer HAIs in 2010, including a 14% decrease of UTIs in residents without a catheter and a 15% decrease in residents with catheters; as well as an 18% decrease of skin and soft tissue infections.

Segal said she expects to see further reductions in HAIs after 2 full-year data are compared at the end of 2011, as data collection only began in June 2009, therefore not representing 12 months of reporting that year. “Any time that drastic changes of this nature are enforced, there is a learning curve, as well as other demands placed on the facilities,” she said.

With the introduction of Act 52 of 2007, nursing homes were also under pressure to increase their resources, particularly in the technology and staffing areas. All nursing homes were required to ensure that computer systems were up to date to accommodate the PA-PSRS reporting system. This created an extra expense for many facilities and the need to hire additional staff, according to Segal.

“However, today, the nursing homes are indirectly ‘thanking’ Rendell for enforcing Act 52, as mandatory reporting has created much of an awareness relating to resident safety and teamwork has increased exponentially within the facilities,” she said.

Barriers to data

Although Segal said mandatory reporting will improve HAIs in nursing homes, others said surveillance reporting is not necessary.

In an interview with Infectious Disease News, Andrea Eikelenboom-Boskamp, MD, infection control practitioner at Canisius-Wilhelmina Hospital in Nijmegen, the Netherlands, said: “HAIs in nursing homes are as prevalent as in hospitals. Consequently, prevalence and incidence studies, as well as infection control measures, should be equally frequent and important.”

Eikelenboom-Boskamp said she recommends applying many of the principles used in the hospital and adapting them to nursing homes, adding that she agrees in implementing mandatory surveillance but not public reporting. “Surveillance should guide your own interventions. Yes, we need more infection control in the nursing home setting, but mandatory reporting will not achieve that, and there’s the question of how accurate the numbers would be.”

Infectious Disease News Editorial Board member R. Brooks Gainer, MD, said there are not enough resources to dedicate to mandatory HAI reporting. “Very few nursing homes have full-time infection control practitioners. It is a complex issue in long-term care facilities, and infection control practices are poor in most nursing homes.

“You can make it mandatory, but how accurate is the data going to be without resources to dedicate someone to do this with all the other cutbacks? Without economic incentive, it’s not going to get done, and if they start penalizing nursing homes for not reporting, it’s going to make it worse,” Gainer said.

Trends across US

Based on the executive summary of the Pennsylvania 2010 Annual Report, “Pennsylvania is a national leader in addressing the challenge of reducing and ultimately eliminating HAIs to prevent unnecessary illnesses and deaths, and to eliminate the avoidable costs of treating these infections.”

According to the Association for Professionals in Infection Control and Epidemiology, California, Florida, Hawaii, Nevada and Oregon have followed in Pennsylvania’s lead and incorporated some type of mandatory reporting in long-term care facilities as of July.

Twenty-six states currently have legislation in progress for HAI reporting in long-term care facilities. However, Segal said no other state has legislation as comprehensive and extensive as Pennsylvania.

“In general, public reporting of HAIs from hospitals and nursing homes is a good concept in order to maximize transparency and inform potential patients,” Smith told Infectious Disease News. “However, these benefits depend on consistent and accurate data being reported from the health care facility.”

Although nursing homes may be concerned about the increased personnel required to collect this information and possible unfair adverse publicity if risk-adjusted data is not collected from nursing homes, Smith said more states will follow the lead of Pennsylvania.

“They should follow the lead if appropriate HAI measures are selected, valid data are collected and states monitor whether the program is cost-effective,” he said. – by Ashley DeNyse

For more information:

• APIC. Legislation in progress. Available at: www.apic.org/map/index.htm. Accessed Aug. 22, 2011.
• CDC. Health care-associated infections (HAIs). Available at: www.cdc.gov/HAI/settings/ltc_settings.html. Accessed Aug. 22, 2011.
• Patient Safety Authority. Act 52 of 2007. Available at: patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Jun5%282%29/Pages/66.aspx. Accessed Aug. 22, 2011.
• Smith PW. Infect Control Hosp Epidemiol. 2008;29:785-814.
• WHO. Report on the burden of endemic health care-associated infection worldwide. Available at: whqlibdoc.who.int/publications/2011/9789241 501507_eng.pdf. Accessed Aug. 22, 2011.

Disclosure: Ms. Segal is an independent consultant with Infection Control Consulting Services. She represented the PSA as its infection prevention analyst from December 2007 to December 2010 and was instrumental in assisting PSA with the mandatory reporting of HAIs to the state. Ms. Segal and Drs. Eikelenboom-Boskamp, Gainer, Kaye and Smith report no relevant financial disclosures.

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