Most staff who deliver home infusion therapy not trained in infection surveillance
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There has been a significant increase in the number of people receiving home infusion therapy over the last decade, but a study found that many who deliver these services have no formal training in infection surveillance.
According to the study published in the American Journal of Infection Control, most nurses and providers delivering home infusion therapy (HIT) are not trained to conduct surveillance for central line-associated bloodstream infection (CLABSI), did not know training was available and generally learned on the job or attended conferences to learn how to monitor for the life-threatening infections.
According to the CDC, between 12% and 25% of patients who develop CLABSI die of the infection. With the HIT population growing by 300% between 2008 and 2019, monitoring for these infections is vital, according to experts.
“Infection preventionists are health care workers, typically with backgrounds in nursing, microbiology or public health who are experts in how to monitor for health care-associated infections and how to prevent them,” Sara Keller, MD, MPH, MSPH, assistant professor in the infectious diseases division at Johns Hopkins University, told Healio.
“It is work that requires training and experience. We were curious about the barriers to looking for — monitoring for or performing surveillance for — these infections in home infusion therapy and what strategies they used,” Keller said.
For the study, Keller and colleagues analyzed a set of 21 interviews with HIT staff from five large academic or nonprofit HIT agencies covering parts of 13 states and Washington, D.C., that were conducted between November 2020 and April 2021.
The interviews were initially conducted for a separate study on CLABSI surveillance methods used by HIT providers. For this study, Keller said the researchers focused on the small number of staff at the agencies monitoring for infections and felt interviews would be more effective than surveys because they were not sure in advance what barriers to training would be expressed and what methods the practitioners would use.
“We learned that those performing surveillance in the agencies had not had formal training in how to monitor for these infections and may not have been aware of the resources,” Keller said.
Staff told the interviewers that they “knew the methodology that’s followed” but had not had any training. Many learned how to perform surveillance “on the job, from their predecessors, and taught their colleagues.” Others, the researchers found, transferred knowledge from previous clinical experience or attempted to supplement their training with resources from governmental agencies and professional societies.
Some practitioners also said they were “self-taught,” having sought out seminars or connections at other agencies to gain knowledge and training — and many said their agencies did not offer training.
The president of the National Home Infusion Association (NHIA) was critical of the study and its outcomes, noting what she said were “significant limitations” in its methods — for example, snowball sampling and semistructured interviews.
"NHIA and the association's members acknowledge that central line-associated bloodstream infection is a serious complication that can occur in patients receiving IV therapies. However, we strongly disagree with the study's conclusions and generalizations about the infection prevention workforce in home infusion," Connie Sullivan, BS Pharm, said in a statement.
"The infusion industry absolutely has specific requirements around monitoring and reporting rates of CLABSI, and several independent, peer-reviewed studies of home-based patients demonstrate lower rates of CLABSI compared to hospital settings. We do not agree that a qualitative study of five agencies is reflective of the entire industry, which consists of nearly 1,000 organizations,” Sullivan said.
Sullivan referenced a 2022 review of 63 studies covering 396,951 catheter days, which found a CLABSI rate of 4.59 per 1,000 catheter days in hospitalized patients. She said several studies show lower rates in home settings, including a 2009 study analyzing 11 years of surveillance from the University of North Carolina Health Care System that found its CLABSI home care rate was between 0 and 0.73 per 1,000 catheter days.
Among the recommendations they made based on the study's findings, Keller and colleagues said staff should be made aware of resources available to them, and that they specifically should be developed for the home setting. They also noted that “approaches to train HIT staff on reproducible and reliable CLABSI are lacking.”
They suggested staff performing surveillance look to enroll in training courses through the CDC, the Association for Professionals in Infection Control or other institutions, “and that they should be provided time to take these courses both when learning and to get continuing education.”
“We also suggested developing learning communities where staff doing this work can ask each other, as well as certified infection preventionists working in acute care hospitals, about challenging cases,” Keller said.
[Editor’s note: This story was updated to include reaction from the NHIA.]
References:
- NHIA. Setting the record straight on home infusion therapy. https://nhia.org/setting-the-record-straight-on-home-infusion-therapy/. Published Jan. 24, 2023. Accessed Jan. 24, 2023
- Oladapo-Shittu O, et al. Am J Infect Control. 2023;doi:10.1016/j.ajic.2022.11.008
- Srinivasan A, et al. MMWR Morb Mortal Wkly Rep. 2011;doi:10.15585/mmwr.mm60e0301
- Study reveals significant lack of infection-surveillance training in home infusion therapy setting. https://apic.org/news/study-reveals-significant-lack-of-infection-surveillance-training-in-home-infusion-therapy-setting/. Published Jan. 12, 2023. Accessed Jan. 20, 2023.
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