For nurses working with home health patients, a family member with unwashed hands or even a pet dog can be frustrating sources of potential infection. They also can provide what one nurse optimistically calls a teachable moment.
The good news is patients are far less likely to acquire an infection at home than in a hospital setting. However, nurses who provide home care have unique challenges and responsibilities when it comes to preventing the spread of germs. Unlike a hospital, where there are trained professionals and an infrastructure to back up a nurses efforts, each patients home is uncharted territory.
In a hospital, caregivers must contend with multiple drug-resistant organisms, surgical-site infections, patient-to-patient transmission, and the like. But they also have access to laboratories to determine the source of infection and appropriate treatment. On the other hand, there is no on-site lab to conduct a quick test in patients homes, so nurses must rely on observations. There may be a pet cat that jumps into a nurses bag, spoiled food in the refrigerator, family members who do not wash their hands, or cockroaches. There also is the risk a nurse might shuttle bacteria from one household to another. But in hospital and home settings, one rule of thumb applies: The greatest risk may come from the infection that has not yet been diagnosed. That means nurses should use caution even when there is no evidence of an infection, experts say.
Home Care in the MillionsStaff Development from left to right includes: Lindsay Manning, RN, Clinical development supervisor; Laudz Cheriel-Burke, RN, staff educator; Evelyn Jounakos, RN, director of Staff Development; Elsie Jean-Bart, RN, clinical development specialist; and Takiysha McLeod, RN, clinical development specialist.
Some 7.6 million individuals receive home care and, in 2007, the Centers for Medicare & Medicaid Services projected annual expenditures for home healthcare to be $57.6 billion, according to the National Association for Home Care & Hospice. Data on infection rates among home-care patients is more elusive, but some of the common sources are related to pressure ulcers, catheters, or central lines, says Mary McGoldrick, RN, an infection prevention author and consultant based in St. Simons Island, Ga., who works with home-care and hospice providers.
In the home, theres no patient-to-patient transmission, she says. Its the nurse and the nurses supplies that are brought into the home that can be the transmitters of these organisms.
Communication and education as well as a dash of creativity are essential aspects of a home-care nurses job, says Gayle Lovato, RN, MS, an infection preventionist with Inova Loudoun Hospital in Leesburg, Va., who explains nurses have to rely on whatever they find in the home to accomplish their goal of preventing the spread of infection.
As youre [taking] the cat off the table, you can say that people who are sick or have infections need to be extra careful, she explains. Youre not going to be changing their lifestyle. You have to deal with what you find.
Closer to Home
At Revival Home Health Care in Brooklyn, N.Y., nurses are expected to examine the home environment when they arrive on the scene and make sure patients and their families know the importance of infection prevention, says Evelyn Jounakos, RN, director of staff development. They look in refrigerators to ensure there is adequate food and that it is kept cold enough. They make sure hot water and convenient hand-washing facilities are available.
The nurse has to look at the broader picture, whereas in the hospital, thats all done for them, Jounakos says.
One of the primary challenges is the nurse is not the only person providing care when a patient is ill at home. What would be most important in those situations is to teach the patient or caregiver about hand hygiene before rendering any patient care, and really doing the best [he or she] can within the care setting to prevent infections, McGoldrick says.
In addition to teaching patients or their family members how to change a dressing or store medical supplies without contaminating them, nurses need to do thorough assessments of both the patient and family members, Jounakos says. They might pick up on an infection before the physician does because they see the patient more often. At Revival, any infections that are discovered are noted and tracked at the administrative level, she says.
Stay Up to Date on Trends
As director of quality improvement, Jyotika Mathur, RN, BSN, MPH(c), tracks infections for Americare Certified Special Services, another home care provider serving the New York area.
The most common infections she sees are urinary tract, respiratory, wound, gastrointestinal, and eye infections, she says. Surveillance is part of her job, and she uses infection data to improve control and prevention practices companywide. My focus is on noticing the trends and then [teaching] because data speaks, she says. It also helps her launch campaigns in areas of concern, such as preparing nurses in advance of the flu season.
These are things that home care agencies do and should do to promote infection control information, Mathur says.
Although nurses may not have the same infection prevention backup support in a home-care setting as in a hospital, those who work in home care say they are drawn to the unique challenges and opportunities working within a patients home and family offer.
Its an unstructured, unpredictable environment, Lovato says. When it goes well, and you see the [results of your teaching], and you see that you are impacting a family and making a change, then its wonderful. Thats the fun part.