A survey of Medicare-certified home healthcare (HHC) agencies reveals minor improvements and problematic declines in infection prevention and control (IPC) staff training, less frequent IPC policy reviews, and fewer agencies with intensive policies for antibiotic stewardship, intravenous (IV) and central catheter infections, and pneumonia since the height of the COVID-19 pandemic.
Led by Columbia University School of Nursing investigators, the study analyzed data from nationally representative Medicare-certified HHC agency surveys conducted in 2019 and 2023. The surveys addressed IPC infrastructure and policies for antibiotic stewardship, urinary tract infection, IV and central catheters, and pneumonia.
The team, which also assigned composite intensity scores for each IPC domain, published the findings yesterday in JAMA Network Open.
"HHC patients face infection risk due to chronic conditions, wounds, medical devices, and a less controlled home environment," the study authors wrote. IPC "is a national patient safety goal, yet a prepandemic survey found wide IPC policy variation, with deficiencies worsening during the pandemic because of personal protection equipment shortages and insufficient IPC training."
Declines in all-staff IPC training
In total, 1,052 surveys were completed (536 in 2019 and 474 in 2023), with 171 agencies completing both. Response rates (36% in 2019, 32% in 2023) were strong for HHC agencies, which the authors characterized as a hard-to-reach group. Weighting accounted for response bias, producing a nationally representative sample (15% rural, 81% for-profit, and 7% hospital-affiliated).
Significant declines in antibiotic stewardship, intravenous and central catheter infection, and pneumonia prevention policies raise concerns about increased infection risks for vulnerable HHC patients.
Fewer IPC staff lacked training in 2023 than in 2019 (14.0% vs 34.1%), and hospital-provided training rose (16.8% vs 1.3%). But IPC training for all staff dropped in 2023, with fewer agencies offering it during employee orientation (52.1% vs 61.0%) and a shift toward virtual rather than in-person education. Committees reviewed IPC policies less often in 2023 (64.5% vs 70.5%), and more agencies said field staffing was the most challenging IPC issue in 2023 (40.5% vs 21.4%).
Declines in policy intensity were noted in three of the four domains, with agencies with high-intensity antibiotic stewardship policies falling from 23.4% in 2019 to 11.8% in 2023. Likewise, high-intensity policies for IV and central catheter infections (from 68.5% to 56.1%) and pneumonia (from 65.9% to 52.4%) also dropped. A sensitivity analysis using longitudinal data from 171 agencies yielded comparable results.
Increased infection risks for the vulnerable
The researchers said that the IPC training decline for all staff may indicate a shift in focus to vaccination surveillance. "Significant declines in antibiotic stewardship, intravenous and central catheter infection, and pneumonia prevention policies raise concerns about increased infection risks for vulnerable HHC patients," they wrote.
Despite increasing attention to IPC during the pandemic, key policies have since weakened, perhaps due to worker shortages and a continued lack of resources, limiting effective program implementation, they added.
"Addressing these challenges requires coordinated and systematic actions," the researchers concluded. "This research was limited by subjective IPC measures; thus, future research should use objective measures to address bias. Investing in workforce capacity, resources, and training is essential for safe and high-quality HHC."
