Health care-associated infections (HAIs) are numerous, costly, and largely preventable events that can cause significant illness–and even death–particularly in vulnerable elderly patients. Nurses are responsible for most direct patient care in health care settings, so they are closely involved with infection control and prevention. Research led by nurse scientists on infection control has helped provide a foundation of evidence and guided best practices in multiple clinical settings.
With support from NINR, Drs. Elaine Larson, Jingjing Shang, and Patricia Stone of the Columbia University School of Nursing have led significant investigations regarding HAI prevention in hospitals, home healthcare, and nursing homes. Some highlights of their work in infection prevention and control (IPC) are described below.
Infections Linked to Fellow Hospital Patients
There is increasing evidence that some HAIs may be associated with hospital roommates or previous occupants of the same hospital bed. In one study, Dr. Larson and colleagues found that patients with HAIs were nearly 5 times as likely as similar patients without HAIs to have been exposed to the same disease-causing agent or pathogen that infected a hospital roommate. Those with HAIs were also almost 6 times as likely to have been exposed to the same pathogen that infected the person who had used the same hospital bed immediately prior to the patient.
The researchers made this discovery after comparing medical records of those with and without HAIs. They also analyzed the clinical microbiology reports of patients in the same room as those included in the study, as well as of patients who occupied the same hospital beds immediately before those in the study.
This study identifies the risk of infection from hospital roommates or previous bed occupants and recommends the widespread use of enhanced cleaning in hospital settings.
State Laws to Improve Infection Control and Prevention
To improve patient safety, a variety of federal and state laws require hospitals to report HAIs, however it is not clear whether these laws have improved outcomes and processes. To better understand the effects of these laws, Dr. Stone and colleagues surveyed hospital IPC departments in hospitals across the U.S. Their analysis found that IPC departments in states with HAI reporting laws had a perception of greater resources and influence on hospital decision-making than those without such laws. However, departments in states with HAI laws also perceived that there was less time for routine IPC activities, and that they had less visibility than departments in states without such laws.
These findings shed light on the potential benefits and possible unintended consequences of state HAI laws.
Infection and Isolation of Nursing Home Residents
Multidrug-resistant organisms (MDROs) are a growing health threat due to their resistance to antibiotic and antimicrobial treatment. Nursing home residents are considered one of the most vulnerable populations to serious illness and death associated with MDROs, compared to patients in other health care settings.
Patient isolation is one of the most effective measures for preventing MDRO transmission, but this practice can be difficult in nursing homes in comparison with other health care settings. Dr. Stone and colleagues looked at data from a national sample of nursing home residents with MDRO infections and learned that isolation was not often used. Even when isolation was used, there was a wide variation in how it was done. They found that nursing homes that received an infection control-related citation within the past year were more likely to use isolation practices, while those that had received a quality-of-care citation were less likely to use isolation practices. They also found that higher nurse staffing levels were associated with lower use of isolation, which could be due to availability of private rooms.
These findings can help identify training strategies and policies on using isolation to lower risk of MDRO transmission.
Infection Control Training
Variation in IPC practices across nursing homes extends to staff training and education in infection control, which can contribute to variations in HAI incidence. To better understand the relationship between HAIs and nursing home staff training, Dr. Stone and colleagues analyzed nursing home data on infection control training methods, frequency, and intensity. Their findings showed that tailored and continuous training of nursing home staff was associated with better HAI control than isolated responses to incidents. More training of nursing home staff–at orientation and at the time of outbreaks–was associated with more robust IPC programs and better, less frequent use of urinary catheters–one of the metrics collected by the Centers for Medicare and Medicaid Services to evaluate nursing home quality.
The analysis supports existing evidence that tailored and continuous training of staff is associated with better HAI control than isolated responses to incidents.
Nurse Staffing and Infection Rates
Most of the direct patient care in hospitals is conducted by nurses, so they are most closely linked to control of HAIs. Previous research has found associations between increased HAIs and lower levels of nurse staffing, but these studies were complicated by inconsistent results, lack of appropriate controls, and aggregated data. Drs. Larson, Shang, Stone and colleagues conducted an analysis of staffing and HAI in a large urban hospital system, building on previous studies while providing greater data consistency. The researchers used a dataset of over 100,000 patients, of which more than 4 percent developed an HAI during hospitalization. They found that patients on units with understaffing of nurses had an 11–15 percent greater risk for HAI compared to patients on units with adequate staffing.
The study’s results corroborate that understaffing is associated with increased risk of HAIs and highlights the significant impact nurse understaffing can have on patient outcomes.
Preventive Practices and Infections
Patients hospitalized in an intensive care unit (ICU) frequently need a specialized, surgically implanted intravenous catheter, or central line, for the delivery of fluids, nutrition, and medications. Central line-associated bloodstream infections are recognized as a grave risk to hospitalized patients, so several health care organizations have promoted a group of five evidence-based interventions, known as a central line bundle, to reduce the incidence of these infections. Drs. Stone and Larson, along with their colleagues, conducted a survey of 984 ICUs in 632 hospitals across the United States and found that following even one of the five evidence-based interventions could reduce these infections. Unsurprisingly, the greatest reduction in infections in intensive care units was seen when all five interventions were followed.
These findings identify practices that could lead to fewer central-line bloodstream infections and better patient outcomes.
Infection Prevention and Control in Home Health Care
Home health care (HHC) is one of the fastest-growing health care sectors in the U.S. and it plays a significant role in patient care after hospitalization. With support from NINR, Drs. Shang and Stone interviewed HHC staff from across the U.S. and learned that staff, patient, and family IPC education and training is perceived as critical to patient safety. However, many interviewees talked about their lack of formal training, as well as the limited number of educational resources focused on IPC in HHC. In a nationwide survey of HHC agencies, Drs. Shang, Stone, and colleagues found that only 30 percent of HHC staff who are in charge of IPC at their agencies have formal IPC training and less than 40 percent of agencies provide IPC training for their staff quarterly or more frequently.
These findings, presented in abstract form, demonstrate a potential weakness in the ability of HHC agencies to respond appropriately to infection outbreaks, and highlight the need to educate staff, patients, family members, and caregivers properly about IPC.