March 13, 2000 (Atlanta) -- Increasing numbers of patients are receiving care at home -- a trend that is putting patients at greater risk of infection -- and placing a huge burden on families, according to research presented at the CDC's 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections held in Atlanta.
Over the past decade, the number of patients receiving care at home has risen dramatically, the CDC report says. An estimated 8 million Americans received home care in 1996, based on the most recent data available. That same year, an estimated 11,400 home care agencies discharged nearly 7.8 million patients, representing 69% and 150% increases in discharged home care patients respectively since 1992.
Nearly 10% of home care patients had an invasive medical device that is typically used in other, more structured health care settings. For example, ventilators, urinary catheters, and intravascular (IV) catheters are used in the home and are all potential sources of infection if not cared for properly, says Robert Gaynes, MD, chief of nosocomial infections surveillance activity in the CDC's hospital infections program.
Gaynes tells WebMD, "The burden is being placed on family caregivers who have to provide that care. A significant challenge lies in making sure that family members are properly educated in health care procedures, in preventing infections. Yet home care agencies -- often, because of economics -- can only supply visiting nurses in some cases no more than twice a week." Health Care Financing Administration reimbursement drives much home care practice, and in many cases is now covering only twice-a-week home care nursing visits.
Preliminary investigations have revealed a very diverse industry, says William Jarvis, MD, chief of investigation and prevention branch for the CDC's hospital infections program. He tells WebMD, "In some instances, we've found that the home health company just delivers supplies to the front porch and family members provide therapy. ... This industry is changing very rapidly. Five to seven years ago, maybe two companies looked like they were going to dominate the market. Now there are hundreds and hundreds of companies that are providing home infusion therapy alone."
To assess the magnitude of the infection rate problem -- and to eventually provide quality-of-care comparisons -- the CDC is beginning to collect data from home care companies across the country, says Jarvis. Without such information, patients and their families will be choosing a home care company -- many of which do not have infection control programs -- without all the facts.
"Otherwise, you're at your local hospital and they have 10 infusion companies they have contracts with. Do you go with the one that's more convenient? I want to go with the one that's best. And unless they're collecting infection data, we really can't compare institutions," says Jarvis.
In providing commentary, John E. McGowan, MD, professor of epidemiology at Emory University's Rollins School of Public Health and professor of Medicine at Emory University School of Medicine, both in Atlanta, tells WebMD, "We have forced families to become health care providers for patients who are sicker than they used to be. I think that's a very difficult burden. We need to put our attention on family health education. It's a clear concern, a clear need."
McGowan adds, "The home health care nurses are now on the clock just like physicians in the hospital. All of a sudden they're obliged to see a certain number of patients in a certain number of minutes, so the amount of education they have the time to provide is limited. I'm sure they have the desire, but they don't have the time to spend with the families to make sure this gets done. These are great burdens, and I applaud the CDC [for] addressing this in more detail."
In the course of monitoring his own patients, Charles Ericsson, MD, head of clinical infectious diseases at the University of Texas School of Medicine in Houston, tells WebMD, "The whole concept [of home care] places a physician like myself in a very awkward position of having the same responsibility for the patient but no way to monitor the patient. I typically insist that the patient get back and see me once a week if they're on four or five more weeks of IV therapy, so I can monitor the site of the line myself because not all nurses are created equal and they sometimes miss symptoms that may be more subtle clues."
Ericsson adds, "If you have the patients themselves [monitoring their own IV lines], with the nurse coming out once a week, which we're seeing more often, it's no surprise to me that the infection rate is going up. It wouldn't surprise me that this is a hidden downside of trying to save money. A serious infection may require a brief hospitalization to not only get the line out but put [the patient] on an antibiotic for the new infection."
To help consumers identify good-quality home care companies, Ericsson offers advice: "You'll get a sense if they appear truly devoted to teaching you exactly what needs to be done and following through to make sure you're doing what you were taught to do."
- Increasing numbers of Americans are receiving health care at home, and many of these patients are using invasive medical devices, placing them at increased risk of an infection.
- Family caregivers must be properly educated in health care procedures and preventing infections.
- Home health care companies can help families and patients, but even high-quality companies' financial constraints often limit the number of visits the company is able to provide.