By Marie Rosenthal, MS
Some home infusion therapy (HIT) staff receive no formal training on performing central line?associated bloodstream infection (CLABSI) surveillance, according to a recent study (Am J Infect Control 2023 Jan 12. https://doi.org/10.1016/j.ajic.2022.11.008).
However, members of the National Home Infusion Association (NHIA) told Infectious Disease Special Edition that this study, which was small, does not reflect home infusion therapy standards and practices, which are stringent.
Sara C. Keller, MD, MSHP, MPH, with Johns Hopkins University School of Medicine, in Baltimore, noted that there has been a 300% increase in the number of U.S. patients receiving HIT between 2008 and 2019. She wondered about the CLABSI surveillance.
“Appropriate, accurate CLABSI surveillance to understand rates in the HIT setting is necessary to drive prevention efforts,” she said.
The NHIA acknowledged that 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, the group’s president and CEO.
In the study, Dr. Keller and her colleagues conducted qualitative interviews with 21 home infusion staff from five large HIT agencies, covering 13 states and Washington, D.C. Questions posed to the staff—all of whom performed surveillance activities—focused on their surveillance training and other factors that could affect CLABSI detection and management.
They found that some HIT staff who performed surveillance received no formal training on CLABSI surveillance. Instead, study participants described a range of informal training experiences that included learning on the job (often from similarly untrained coworkers), relying on past experience and attending conferences. Participants also cited a lack of learning resources such as user-friendly tool kits that accommodate high workload and time pressures; lack of awareness of professional development resources available to them; and lack of formal training provided by their organizations.
“These findings illustrate that there is a great need for infection prevention personnel and expertise in HIT,” said Patricia Jackson, RN, BSN, CIC, FAPIC, the 2023 president of the Association of Professionals in Infection Control. “This information should prompt a concerted effort to implement formal infection prevention and surveillance training for HIT staff, including the development and deployment of training tools specific to the HIT setting.”
However, Ms. Sullivan said this effort already is underway.
Home infusion providers routinely collect and report data on CLABSI as part of their quality improvement programs, as required by accreditation standards issued by the Joint Commission, Accreditation Commission for Health Care and other organizations. The NHIA also strongly encourages members to assess catheter infections as part of their quality improvement programs, and has published a standard definition to assist in identifying suspected access device infections.
“The infusion industry absolutely has specific requirements around monitoring and reporting rates of CLABSI,” Ms. Sullivan noted. “Several independent, peer-reviewed studies of home-based patients demonstrate lower rates of CLABSI compared with hospital settings. We do not agree that a qualitative study of five agencies is reflective of the entire industry, which consists of nearly 1,000 organizations.”
There is an “abundance” of peer-reviewed studies demonstrating the safety of home infusion, with data showing that infusion infection rates are, in fact, much lower in the home than in hospital settings, the NHIA said. As an example, a systematic review of 63 studies covering 396,951 catheter-days found a CLABSI rate of 4.59 per 1,000 catheter-days in hospitalized patients (Crit Care Med 2018;46[12]:1998-2009). By contrast, the home and ambulatory care literature consistently shows CLABSI rates of less than one per 1,000 catheter-days (Infect Control Hosp Epidemiol 2009;30[10]:1022-1024).
Most CLABSI studies in home infusion look at the highest-risk patients and therapies (e.g., parenteral nutrition). The 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, the NHIA added.
“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,” said Tim Affeldt, the 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.”
