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NHIA Statement on Infection Control Surveillance in Home Infusion

NHIA is disappointed by the characterization of a recent study regarding infection control in home infusion, which the association asserts is not at all reflective of home infusion therapy standards and practices.

“NHIA and the association’s members acknowledge that central line-associated bloodstream infection (CLABSI) 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,” said Connie Sullivan, BSPharm, President and CEO. “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 5 agencies is reflective of the entire industry, which consists of nearly 1,000 organizations.”

“As part of a major health system with a large home infusion program, I can say that the portrayal of the information in this very small study is not at all reflective of my experience and how our home infusion program works,” says Tim Affeldt, Vice President of Specialty/Infusion Operations at Fairview Pharmacy Services in Minneapolis. “Home infusion is a valued link in the continuum of care, allowing lower acuity patients to return to home and work sooner. With good patient education and regular contact from our multidisciplinary care team, we see excellent outcomes.”

NHIA appreciates Axios updating their story about the study with the researcher’s statement clarifying that infection rates are typically lower in the home than for patients treated in hospital-based settings:

“That doesn’t mean infection rates are higher outside the hospital. The best available data shows infections occur at a lower rate than in the hospital. But, because there are more and more people in home care, it is something we need to pay attention to.”

CLABSI Data in Home Infusion

There is an abundance of peer-reviewed studies demonstrating the safety of home infusion and infusion infection rates are in fact much lower in the home compared to hospital settings.

For example, a systematic review of 63 studies covering 396,951 catheter days found a CLABSI rate of 4.59 per 1,000 catheter days (4.59/1000) in hospitalized patients.1 Similarly, a study of critically ill hospital patients covering 11,110 catheter days found a rate of 6.03/1,000 for patients with central venous catheters and a rate of 1.62/1,000 in patients with peripherally inserted central catheters (PICCs).2

By contrast, the home and ambulatory care literature consistently shows CLABSI rates of less than 1 per 1,000 catheter days. For example: An 11-year surveillance from the University of North Carolina Health Care System found that its home care CLABSI rate was between 0 and 0.73/1,000.7 References to other studies are provided below.3,4,5,6

Most CLABSI studies in home infusion look at the highest risk patients and therapies (e.g., parenteral nutrition). The CLABSI rates would likely be even lower across the entire home infusion population because most home infusion patients are not critically ill and are receiving short-term courses of IV antibiotics, which puts them at very low risk for CLABSI.

CLABSI Reporting in Home Infusion

Home infusion providers routinely collect and report data on CLABSI as part of their quality improvement programs as required by accreditation standards issued by Joint Commission, Accreditation Commission for Health Care (ACHC), and others. NHIA also strongly encourages members to assess catheter infections as part of their quality improvement programs and has a published a standard definition to assist in identifying suspected access device infections.

Study Design

Studies using qualitative methodology have known limitations, including small samples sizes, potential bias in answers, self-selection bias, and potentially poor questions from researchers. Furthermore, researchers that use a technique called “snowballing” to recruit participants, which involves asking one participant if they know others who would be willing to be interviewed, risk introducing bias due to the non-random nature of selecting participants. These methods make it impossible to generalize the study findings to other situations and populations.

References:

  1. Takashima M, Schults J, Mihala G, Corley A, Ullman A. Complication and Failures of Central Vascular Access Device in Adult Critical Care Settings. Crit Care Med. 2018 Dec;46(12):1998-2009. doi: 10.1097/CCM.0000000000003370. PMID: 30095499.
  2. Pitiriga V, Bakalis J, Theodoridou K, Kanellopoulos P, Saroglou G, Tsakris A. Lower risk of bloodstream infections for peripherally inserted central catheters compared to central venous catheters in critically ill patients. Antimicrobial Resistance & Infection Control. 2022;11(1). doi: 10.1186/s13756-022-01180-1.
  3. Curley M, Larson J, Pomputius WFI, Maynard R. Central Vascular Access Device Complications in Pediatric Home Care Patients Managed by Family Caregivers or Nurses. Journal of Infusion Nursing. 2021;44(2):68-77. doi: 10.1097/nan.0000000000000417. PubMed PMID: 00129804-202103000-00002.
  4. Akhtar N, Lee L. Utilization and Complications of Central Venous Access Devices in Oncology Patients. Current Oncology. 2021;28(1):367-77. doi: 10.3390/curroncol28010039.
  5. Cotogni P, Mussa B, Degiorgis C, De Francesco A, Pittiruti M. Comparative Complication Rates of 854 Central Venous Access Devices for Home Parenteral Nutrition in Cancer Patients: A Prospective Study of Over 169,000 Catheter-Days. Journal of Parenteral and Enteral Nutrition. 2021;45(4):768-76. doi: https://doi.org/10.1002/jpen.1939.
  6. Buchman AL, Opilla M, Kwasny M, Diamantidis TG, Okamoto R. Risk factors for the development of catheter-related bloodstream infections in patients receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr. 2014 Aug;38(6):744-9. doi: 10.1177/0148607113491783. Epub 2013 Jun 6. PMID: 23744839.
  7. Weber, D., Brown, V., Huslage, K., Sickbert-Bennett, E., & Rutala, W. (2009). Device-Related Infections in Home Health Care and Hospice Infection Rates, 1998–2008. Infection Control & Hospital Epidemiology, 30(10), 1022-1024. doi:10.1086/605641

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