Home Health Staff Perspectives on Infection Prevention and Control: Implications for Coronavirus Disease 2019

Educational needs of community visiting nurses for infection prevention and control: Application of the Borich needs assessment and the Locus for Focus models

OBJECTIVES

This study aimed to assess the educational needs and analyze the priorities of infection prevention and control (IPC) for community-visiting nurses.

DESIGN

This is a cross-sectional descriptive study.

SAMPLE

This study was conducted with 144 visiting nurses working in public health centers and long-term care facilities in South Korea.

METHOD

A total of 23 questions in five subcategories were used to measure the current knowledge and perceived importance of IPC in community-visiting nursing. Data were collected from June 23 to October 30, 2021, during the COVID-19 pandemic. Data were analyzed paired t-test, the Borich needs assessment, and the Locus for Focus models.

RESULTS

Top-priority content was defined as content belonging to two models, the first 10 contents of Borich needs assessment and the contents located in the Quadrant I of the Locus for Focus models. "Reporting in case of infection-related accidents," "Mandatory vaccination for visiting nurses," "Standard precaution," "Airborne precaution," "Contact precautions," "Respiratory infection control," and "Post-visit management."

CONCLUSIONS

This study suggests that it is necessary to provide visiting nurses with more opportunities for IPC education and to develop standardized IPC programs that consider educational priorities.

Barriers and facilitators to infection prevention practices in home healthcare: a scoping review and proposed implementation framework

Infection prevention and control (IPC) research has focused on the hospital setting, neglecting the rapidly expanding home healthcare (HHC) sector. Current infection prevention recommendations do not reflect the challenges specific to the HHC setting. This scoping review considered any original studies reporting on barriers or facilitators to infection prevention practices in the context of HHC. Study characteristics were mapped, and a descriptive content analysis was performed. Based on the findings we propose a framework of eight HHC setting characteristics relevant to infection prevention implementation. 33 studies fulfilled the eligibility criteria. A majority of studies addressed sharps injury or blood and body fluid exposure prevention (N=15) and the majority were conducted in the United States (N=23). Study methodologies employed were surveys (N=18), qualitative (N=11), direct observation (N=7), and one interventional study. The HHC setting characteristics relevant to infection prevention implementation were: the care process in the patient's immediate environment; the need to bring equipment and materials into the home; the provision and financing of equipment and materials; the use of patient space and facilities; the unique position of and the expectations towards HHC providers; working alone with little support; the intermittent nature of care; the attitudes of HHC providers formed by their work circumstances. Interventional studies generating higher-quality evidence for implementation are lacking. Furthermore, implementation of aseptic technique and the decontamination and reprocessing of equipment are poorly studied in the HHC setting and deserve more research interest. The proposed framework may guide future research and implementation work.

Barriers to infection prevention and control in patients' homes

While there is a lot of emphasis on the need for good infection prevention and control practices and acute care, the increasing complexity of patients being cared for in their own homes means that there is an increased risk for infection. Good practice is required by community nurses to minimise this risk. Patients' own homes can present particular challenges in complying with good practice and this article looks at some of the barriers to optimum infection prevention and control precautions in this setting.

Health Information Technology Adoption at U.S. Home Health Care Agencies: Results from a Multi-Methods Study

Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; (4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR; an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.

Exploring behavioural factors influencing COVID-19-specific infection prevention and control measures in Finland: a mixed-methods study, December 2020 to March 2021

BackgroundCompliance with infection prevention and control (IPC) measures is critical to preventing COVID-19 transmission in healthcare settings.AimTo identify and explain factors influencing compliance with COVID-19-specific IPC measures among healthcare workers (HCWs) in long-term care facilities (LTCF) in Finland.MethodsThe study included a web-based survey and qualitative study based on the Theoretical Domains Framework (TDF). The link to the anonymous survey was distributed via email to LTCFs through regional IPC experts in December 2020. Outcome was modelled using ordinary logistic regression and penalised ridge logistic regression using regrouped explanatory variables and an original, more correlated set of explanatory variables, respectively. In-depth interviews were conducted among survey participants who volunteered during January-March 2021. Data were analysed thematically using qualitative data analysis software (NVIVO12).ResultsA total of 422 HCWs from 17/20 regions responded to the survey. Three TDF domains were identified that negatively influenced IPC compliance: environmental context and resources, reinforcement and beliefs about capabilities. Twenty HCWs participated in interviews, which resulted in identification of several themes: changes in professional duties and lack of staff planning for emergencies (domain: environmental context and resources); management culture and physical absence of management (domain: reinforcement), knowledge of applying IPC measures, nature of tasks and infrastructure that supports implementation (domain: beliefs about capabilities), that explained how the domains negatively influenced their IPC behaviour.ConclusionsThis study provides insights into behavioural domains that can be used in developing evidence-based behaviour change interventions to support HCW compliance with pandemic-specific IPC measures in LTCFs.

Urinary catheter policies in home healthcare agencies and hospital transfers due to urinary tract infection

BACKGROUND

Urinary tract infections (UTIs) are a frequent cause of hospital transfer for home healthcare (HHC) patients, particularly among patients with urinary catheters.

METHODS

We conducted a cross-sectional, nationally representative HHC agency-level survey (2018-2019) and combined it with patient-level data from the Outcome and Assessment Information Set (OASIS) and Medicare inpatient data (2016-2018) to evaluate the association between HHC agencies' urinary catheter policies and hospital transfers due to UTI. Our sample included 28,205 patients with urinary catheters who received HHC from 473 Medicare-certified agencies between 2016-2018. Our survey assessed whether agencies had written policies in place for (1) replacement of indwelling catheters at fixed intervals, and (2) emptying the drainage bag. We used adjusted logistic regression to estimate the association of these policies with probability of hospital transfer due to UTI during a 60-day HHC episode.

RESULTS

Probability of hospital transfer due to UTI during a HHC episode ranged from 5.62% among agencies with neither urinary catheter policy to 4.43% among agencies with both policies. Relative to agencies with neither policy, having both policies was associated with 21% lower probability of hospital transfer due to UTI (P < .05).

CONCLUSION

Our findings suggest implementation of policies in HHC to promote best practices for care of patients with urinary catheters may be an effective strategy to prevent hospital transfers due to UTI.

Adherence to Personal Protective Equipment Use in Home-Care Service Agencies During COVID-19 in Japan: A Cross-Sectional Survey

OBJECTIVES

To assess adherence to personal protective equipment (PPE) use among home care workers during usual care at the agency level during the COVID-19 pandemic in Japan and determine whether agency-level action toward infection prevention and control (IPC) is associated with adherence to PPE use.

DESIGN

A nationwide cross-sectional study.

SETTING AND PARTICIPANTS

Home care service agencies in Japan were randomly selected from all agencies nationwide.

METHODS

An online survey was conducted between January and February 2021. The administrators at home care service agencies responded to the following items: adherence to PPE (disposable masks, gloves, and aprons) use during diaper change among their home care workers, agency-level actions toward IPC, including monitoring of infection outbreak among users, existing manual for IPC, training opportunities on IPC for care workers, and other agency and administrator characteristics.

RESULTS

Of the 1942 agencies, 197 were included in the analysis (response rate: 10.1%). Although 145 (73.6%) of the agencies always used both masks and gloves during diaper change, 32 (16.2%) agencies fully adhered to wearing masks, gloves, and aprons. Agencies monitoring infectious disease outbreaks among service users were more likely to adhere to PPE use (adjusted odds ratio: 5.97, 95% confidence interval: 1.30-27.31).

CONCLUSIONS AND IMPLICATIONS

Low adherence to PPE use, especially apron use, during diaper change among home care service agencies during the COVID-19 pandemic in Japan was revealed, despite the widespread availability of a manual for IPC and/or training opportunities. To ensure safety and quality home care services for both users and home care workers, agencies should not simply create manuals or training systems as a structure; instead, they should implement effective processes for appropriate PPE use.

The Effects of Home Health Value-Based Purchasing on Home Health Care Quality in For-Profit and Nonprofit Agencies: A Comparative Interrupted Time-Series Analysis, 2012-2018

Beginning in 2016, the Home Health Value-Based Purchasing (HHVBP) model incentivized U.S. Medicare-certified home health agencies (HHAs) in nine states to improve quality of patient care and patient experience. Here, we quantified HHVBP effects upon quality over time (2012-2018) by HHA ownership (i.e., for-profit vs. nonprofit) using a comparative interrupted time-series design. Our outcome measures were Care Quality and Patient Experience indices composed of 10 quality of patient care measures and five patient experience measures, respectively. Overall, 17.7% of HHAs participated in the HHVBP model of which 81.4% were for-profit ownership. Each year after implementation, HHVBP was associated with a 1.59 (p < .001) percentage point increase in the Care Quality index among for-profit HHAs and a 0.71 (p = .024) percentage point increase in the Patient Experience index among nonprofits. The differences of quality improvement under the HHVBP model by ownership indicate variations in HHA leadership responses to HHVBP.

Prevalence and Predictors of Persistence of COVID-19 Symptoms in Older Adults: A Single-Center Study

Objectives

Symptom persistence weeks after laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) clearance is a relatively common long-term complication of Coronavirus disease 2019 (COVID-19). Little is known about this phenomenon in older adults. The present study aimed at determining the prevalence of persistent symptoms among older COVID-19 survivors and identifying symptom patterns.

Design

Cross-sectional study.

Setting and Participants

We analyzed data collected in people 65 years and older (n = 165) who were hospitalized for COVID-19 and then admitted to the Day Hospital Post-COVID 19 of the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS (Rome, Italy) between April and December 2020. All patients tested negative for SARS-CoV-2 and met the World Health Organization criteria for quarantine discontinuation.

Measures

Patients were offered multidisciplinary individualized assessments. The persistence of symptoms was evaluated on admission using a standardized questionnaire.

Results

The mean age was 73.1 ± 6.2 years (median 72, interquartile range 27), and 63 (38.4%) were women. The average time elapsed from hospital discharge was 76.8 ± 20.3 days (range 25−109 days). On admission, 137 (83%) patients reported at least 1 persistent symptom. Of these, more than one-third reported 1 or 2 symptoms and 46.3% had 3 or more symptoms. The rate of symptom persistence was not significantly different when patients were stratified according to median age. Compared with those with no persistent symptoms, patients with symptom persistence reported a greater number of symptoms during acute COVID-19 (5.3 ± 3.0 vs 3.3 ± 2.0; P < .001). The most common persistent symptoms were fatigue (53.1%), dyspnea (51.5%), joint pain (22.2%), and cough (16.7%). The likelihood of symptom persistence was higher in those who had experienced fatigue during acute COVID-19.

Conclusions and Implications

Persistent symptoms are frequently experienced by older adults who have been hospitalized for COVID-19. Follow-up programs should be implemented to monitor and care for long-term COVID-19–related health issues.

The state of infection prevention and control at home health agencies in the United States prior to COVID-19: A cross-sectional study

BACKGROUND

Home health care is a rapidly growing healthcare sector worldwide. Home health professionals face unique challenges related to preventing and controlling infections, which are likely to amplify during an infectious disease outbreak (e.g. SARS-CoV-2). Little is known about the current state of infection prevention and control-related policies and outbreak preparedness at U.S. home health agencies.

OBJECTIVES

In this study, we conducted a national survey to assess infection prevention and control-related policies, infrastructure, and procedures prior to the SARS-CoV-2 pandemic.

DESIGN

Cross-sectional study.

SETTING/PARTICIPANTS

Using a stratified random sample of 1506 U.S. home health agencies, we conducted a 61-item survey (paper and online) from November 9, 2018 to December 31, 2019.

METHODS

Survey data were linked to publicly-available data on the quality of patient care, patient satisfaction, and other agency characteristics. Probability weights were developed to account for sample design and nonresponse; Pearson's χ2, Fisher's exact, t-tests or linear regression were used to compare the universe of agencies/respondents and urban/rural agencies.

RESULTS

35.6% of agencies responded (n = 536). Most home health personnel in charge of infection prevention and control have other responsibilities; one-third have no formal infection prevention and control training. Rural agencies are more likely to not have anyone in charge of infection prevention and control compared to those in urban areas. About 22% of agencies implement recommended guidelines when administering antibiotics. Less than a third (26.4%) report that their staff vaccination rates were higher than 95% during the last flu season. Only 48.1% of agencies accept patients requiring ventilation, and of those, 40.9% located in rural areas do not have specific infection prevention and control policies for ventilated patients, compared to 20.8% in urban areas (p < 0.001). Only 39.7% of agencies provide N95 respirators to their clinical staff; rural agencies are significantly more likely to provide those supplies than urban agencies (50.7% vs. 37.7%, p = 0.004). Lastly, agencies report their greatest challenges with infection prevention and control are collecting/reporting infection data and adherence to/monitoring of nursing bag technique.

CONCLUSIONS

Prior to the SARS-CoV-2 pandemic, we found that infection prevention and control was suboptimal among U.S. home health care agencies. Consequently, most agencies have limited capacity to respond to infectious disease outbreaks. Staff and personal protective equipment shortages remain major concerns, and agencies will need to quickly adjust their existing infection prevention and control policies and potentially create new ones. In the long-term, agencies also need to improve influenza vaccination coverage among their staff. Tweetable abstract: Infection prevention and control infrastructure, policies and procedures and outbreak preparedness at U.S. home health agencies was found to be suboptimal in nationally-representative survey conducted just prior to the COVID-19 pandemic.