How Does Infection Risk Differ By Healthcare Setting?

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How Does Infection Risk Differ By Healthcare Setting?

By: Rebecca Moore |

According to the World Health Organization, hundreds of millions of patients are affected by healthcare-associated infections (HAIs) worldwide each year, and of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one HAI.1 With so many different types of healthcare settings providing patient care today, there is an incredible need for all of them to have a heightened awareness about their role in infection prevention. While there are standard precautions that all healthcare professionals should be following, there are some distinctions that can be made for different types of healthcare settings. In this article, we’ll discuss the nuances in risk factors and why different settings may need additional or adapted procedures.

Start Here: Basic Guidelines and Outpatient Setting Risk Factors

A few weeks ago, we published the 5 Ways to Improve Infection Prevention in Outpatient Settings, based on the Centers for Disease Control’s (CDC) Guide to Infection Prevention for Outpatient Settings. In this article, we discussed the special risk factors that outpatient settings pose, as well as the essential tenets of infection prevention for all healthcare settings:

Improve Hand Hygiene

Soap and Water vs. Hand Sanitizer
Where and When to Perform Hand Hygiene

Wear Personal Protective Equipment (PPE)

When to Wear Personal Protective Equipment

Emphasize Injection Safety

Injection Safety Do’s and Don’ts

Complete Thorough Environmental Cleaning

Surface Disinfection Best Practices

Establish Respiratory Hygiene/Cough Etiquette
Other Fundamentals of Infection Prevention

After reviewing that article, come back and read on about how acute care and home health settings require different infection control considerations!

Unique Infection Prevention Risk Factors in Acute Care Settings

Each year in the United States, about 1 in 25 hospital patients is diagnosed with at least one infection related to hospital care alone.2 While great strides in both policy and training have been made to control these numbers throughout the years, there are a few special factors that give acute care facilities additional HAI risk when compared to outpatient clinics.

1. Average Length of Stay is Longer

While patients are usually through an appointment in an outpatient setting in a few hours or less, the average hospital stay is 6.1 days.3 Studies show that increased length of stay can increase the probability of a complication,4 which means that an increased attention to infection control procedures and guidelines is warranted in acute care settings.

2. The Care is Usually More Hands-On and Patient-Centric

Instead of a short visit with just a few medical professionals in an outpatient clinic, patients who are admitted in acute settings require 24-hour care from different clinical staff. Because these professionals are hopping from patient to patient for hours on end, the likelihood of transmitting germs from one room to another are greatly increased.

3. The Patient Population is Often Older and More Vulnerable

In 2017, 4.4% of those 44 years of age and younger reported at least one night stay in the hospital over the last 12 months, while 11.6% of people 45 years of age or older reported at least one night stay.5 This means older patients are more likely to be admitted to the hospital than younger patients, and the older the patient, the more susceptible they are to catching an infection.

“Older adults become more susceptible to infections due to several factors. As people get older, it is more frequent that they have comorbid conditions, such as diabetes, renal insufficiency and arthritis. Many comorbid conditions, both the number and type of comorbid conditions, predispose people to infections. Often, when people age, there is immunosenescence, which means that the immune system doesn’t function as well or as vigorously. The combination of increased comorbid conditions and the decrease in activity of the immune system can make people more prone to infections. The other syndrome that occurs when people become old is frailty. When people become frail, their body mass index drops and they have a harder time functioning independently, in terms of their daily living activities. They become more prone to falls and injuries. All of these things predispose older people to infections.”6

4. Hours are Longer, So More Patients are Being Seen per Day

“In acute care, a patient's risk for hospital-acquired infection is related not only to the severity of illness and exposure to invasive interventions and devices but also to environmental risks, including exposure to other patients and inanimate reservoirs of hospital-acquired pathogens.”7 While outpatient settings are only open for limited hours during the day, acute care facilities are open 24/7. Hospitals see an incredible number of patients each day for a variety of illnesses, injuries and ailments, and this diverse landscape of pathogens naturally create a high-risk environment for germ transmission.

5. A Faster Pace Can Make it More Difficult to Perfectly Adhere to Proper Infection Prevention Practices

With so many patients to care for and so many nonpatient-care duties like charting, it can be easy to overlook even the most basic infection control fundamentals. In fact, on average, healthcare providers clean their hands less than half of the times they should.8 This decrease in attention to detail leaves patients at a higher risk of acquiring HAIs.

6. The Patients are Usually More Ill

Hospitals care for the sickest patients, and these patients often require an additional layer of infection prevention procedures. Often, this means healthcare professionals must follow isolation precautions as well as transmission-based precautions like:

Contact Precautions:

According to the CDC, contact precautions should be used for patients with known or suspected infections that represent an increased risk for contact transmission, like Clostridium difficile (C. diff). These precautions include:9

Ensure appropriate patient placement in a single patient space or room if available in acute care hospitals. In long-term and other residential settings, make room placement decisions balancing risks to other patients. In ambulatory settings, place patients requiring contact precautions in an exam room or cubicle as soon as possible.
Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient’s environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
Limit transport and movement of patients outside of the room to medically-necessary purposes. When transport or movement is necessary, cover or contain the infected or colonized areas of the patient’s body. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. Don clean PPE to handle the patient at the transport location.
Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.
Prioritize cleaning and disinfection of the rooms of patients on contact precautions ensuring rooms are frequently cleaned and disinfected (e.g., at least daily or prior to use by another patient if outpatient setting) focusing on frequently-touched surfaces and equipment in the immediate vicinity of the patient.

Airborne Precautions

The CDC also says that airborne precautions must be used for patients known or suspected to be infected with pathogens transmitted by the airborne route, like tuberculosis, measles or chickenpox. These precautions include:9

Source control: put a mask on the patient.
Ensure appropriate patient placement in an airborne infection isolation room (AIIR) constructed according to the Guideline for Isolation Precautions. In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patient and placing the patient in a private room with the door closed will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an AIIR or returned home.
Restrict susceptible healthcare personnel from entering the room of patients known or suspected to have measles, chickenpox, disseminated zoster, or smallpox if other immune healthcare personnel are available.
Use personal protective equipment (PPE) appropriately, including a fit-tested NIOSH-approved N95 or higher level respirator for healthcare personnel.
Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical mask, if possible, and observe Respiratory Hygiene/Cough Etiquette. Healthcare personnel transporting patients who are on Airborne Precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered.
Immunize susceptible persons as soon as possible following unprotected contact with vaccine-preventable infections (e.g., measles, varicella or smallpox).

Unique Infection Prevention Risk Factors in Home Health Settings

“Efforts to decrease length of hospital stay and shift care to ambulatory settings, as well as patient and family preference to receive care at home, have contributed to the substantial growth of home care in the past decade. As life expectancy in the U.S. population continues to increase and patients with chronic illnesses live longer, home care will continue to expand.”10

As home care expands, the need for its own guidelines of infection prevention and control are growing. Here are the three ways in which home health settings differ from outpatient and acute care settings when it comes to infection risk.

1. You’re Working with More than the Patient

In typical acute and outpatient settings, infection prevention is practiced by healthcare professionals and taught to the patient. However, home health settings are unique because of the sporadic timing of healthcare from a nurse or other professional. Much of home care is provided by family members in a setting that is much less structured and controlled than the hospital environment.11 Therefore, infection prevention must be taught to the patient, their family members and any other caregivers that support them on a regular basis.

"The nurse or other care provider visits the home several times a week, depending on what the patient's care needs are. The nurses are teaching both the patient and the family members how to perhaps perform wound care, or how manage a medical device such as a Foley catheter. So it does raise the stakes for infection -- just as we have breaches in infection control that lead to infections among hospital staff, there can be breaches in protocol among patients and family members providing care.”12

2. Patients Who are Still Sick with Serious Diseases are Going Home

With the acuity of home healthcare on the rise, more complex equipment and procedures can be done outside of the hospital. Therefore, more patients are opting into the home health setting, but in doing so are taking the risk of transmitting serious diseases home with them. This not only puts the patient’s family and caregivers at risk, but it also puts other home health patients at an increased risk for HAIs.

"More patients are coming home with more devices, more drug-resistant organisms, so it's critical that the nurses be very careful in how they manage their equipment and supplies, and that they are not bringing those organisms into another patient's home that may never have been exposed to them… The focus on transmission-based precautions is very important.”13

3. Less External Resources than Other Settings

While infection prevention practices should technically mirror those that are performed in acute and ambulatory settings, home health professionals often have to pair down these practices to what is feasible at their scale.

"Home care and hospice nurses have always adapted and applied infection prevention and control strategies to the best of their abilities with few, if any, external resources. Although home care and hospice nurses are knowledgeable in the basics of infection control, they often face a significant challenge when adapting acute care practice to the home care setting. This adaptation has resulted in a wide variation of practices and methods for patient care (e.g., cleaning and disinfecting equipment, using clean versus sterile technique), as well as the development of many ritualistic, arbitrary practices that have been codified in the home care and hospice organization’s policies and procedures."14

Together, We Can Decrease HAIs and Keep Patients Safe

No matter what setting you practice in, infection prevention is one of the most critical ways you can advocate for the safety and wellbeing of your patients. To learn more about how to reduce HAI’s in acute care, check out the CDC’s comprehensive Infection Prevention and Control Assessment Tool for Acute Care Hospitals. This document will help you audit facility demographics, infection control programs/infrastructure and direct observation of facility practices. For home health settings, learn more about how you can stop the spread of germs with the basics of Infection Prevention and Control at Home. Don’t forget to share this article with your colleagues to keep everyone educated and accountable!

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