Infection Control in the Home Care Setting
By Jean McCaslin, RN IgCN CNE - (Article Updated: January 4, 2022)

Regardless of the site-of-care, infection control is a vital component of patient care. For the purposes of this blog, I will highlight infection control concerns and mitigation in the home infusion space; specifically, those in the plasma-derived therapy sector through Nufactor.

Nufactor cares for patients who receive immune globulin (IG), infliximab, and bleeding disorder products. Diagnoses run the gamut. One universal concern is that many people are already compromised by their associated disease process, for which they receive their life-saving or life-enhancing therapeutic agent. The policies adopted by each patient care provider should be fully transparent. Patients and clinicians should be provided education on universal precautions, as well as ample supplies to conduct sound infection control practices regardless of, and especially due to, certain patient risk factors.

1. Standardization based on historic and current data-driven metrics:

While most homes, pharmacies, and RN dwellings are not hot spots of infective processes, it is best to assume that each home infusion patient is at risk for infectious contamination. Instituting rigorous infection control measures in a standard manner assists in preventing the spread of unknown pathogens.

1. Standard ("universal") Precautions
   Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. Guidelines are designed to prevent transmission of infections from viruses and bacteria that can be found in blood and bodily fluids such as Human Immunodeficiency Virus (HIV), Hepatitis B, Hepatitis C and Methicillin Resistant Staph Aureus (MRSA). Standard Precautions apply to blood, other bodily fluids containing visible blood, semen, and vaginal secretions. Standard Precautions also apply to tissues and to fluids such as cerebrospinal (brain), synovial (between joints), pleural (around lungs), peritoneal (around abdomen), pericardial (around heart) and amniotic (around the fetus in utero).
2. Patient education materials
   Nufactor patient training materials on medication administration follow aseptic technique practices. Many therapies are self-administered (bleeding disorder drugs and SCIG). Patients must be trained in proper hand washing as well as aseptic technique when handling their medication and associated supplies. Return demonstration is essential, as is post-training follow-up to assess continued adherence to infection control measures.
   Nufactor's New Patient Packet contains information on infection control, including Standard Precautions and handwashing.
3. Nufactor pharmacy staff education materials
   Infection control is highlighted in new employee orientation as well as on an ongoing basis throughout employment. Employees must remain current on this training and are provided with updates as warranted. Hand sanitation stations are readily available in multiple locations in all Nufactor facilities. Reminder signage are also posted as appropriate.
   Pharmacists and in-house nursing staff are trained on the use of patient screening and education materials to identify potential or actual concerns in the home surrounding infection control.
4. Home infusion nurse education materials
   Nurses must provide certification of infection control courses and certifications as mandated by their individual state licensing entity. In addition, all nurses seeing patients in the field must complete training with a Nufactor Clinical Nurse Educator prior to conducting nursing visits. Training includes both RN infection prevention measures as well as to conduct a thorough review of infection control education materials with patients during home visits. When threats to appropriate measures are noted, Nufactor is notified in order that thorough evaluation be conducted and corrective measures be taken.
5. Risk assessment tools
   An important aspect of infection control is the development of assessment tools. When a new threat is identified, proper screening tools must be developed, utilized, and adapted based on recommended changes from local Department of Health (DOH) and/or the CDC (also see COVID-19 Pandemic section). This is true under all circumstances; not only during an identified or emerging threat.
   In-house Nufactor nursing personnel are held to the same standards; they are provided with infection control learning materials upon orientation and on an ongoing basis. They are instrumental in the identification of breaks in infection control, as well as in the development of process improvement methodology.
6. Supplies
   In addition to the delivery of medication and supplies (administration tubing, syringes, etc.), PPE must be provided. In most instances, gloves are all that is needed as a barrier between assigned nurses and patient bodily fluids. For some procedures, a surgical mask may also be needed. PPE items should be adapted under unusual circumstances (see COVID-19 Pandemic section).
   Nurses are provided sterile supplies as warranted for accessing in-dwelling infusion devices. When possible, needleless devices and anti-reflux angiocaths should be provided for peripheral access. Recapping of any sharp devices must not be done. The sharps disposal container should be within arms- reach and needles should immediately be discarded in it.
   Sharps containers and education on their proper use must also be provided. Unused biological products must not be disposed of in ordinary garbage, but instead discarded in the sharp's container. Trace amounts remaining in a vial may be discarded in ordinary trash.
   Empty vials from medication used as well as the IV tubing, and gloves may be discarded in ordinary garbage. Dressings and gloves heavily saturated with blood may also be placed in the sharp's container; but generally speaking/when not saturated, may also be placed in ordinary trash.
7. Communication
   An essential element of infection control is communication; between patients, family members, home infusion nurses, and all assigned specialty infusion pharmacy staff. Barriers to learning and breaks in infection control techniques must be reported and discussed so that reeducation can take place.
   RNs, as well as all pharmacy staff should report temperature elevation, potential viral exposure, or known infective processes in order that thorough follow-up be conducted. Nufactor staff should be notified so that the prescribing MD office be notified, and orders be obtained as needed. Delays in scheduled infusion dates should be reported as well.
   

2. Review:

An integral part of any plan is to do a periodic "pulse-check" to assess adherence and deficits. These tactics allow for changes, or the opportunity for Process Improvement methodology.

1. Individual patient outcome data
   The collection of adverse drug events is a well-established practice. But it is also critical to collect information from individual patients to identify specific untoward events such as infections in order that we understand any contributing factors such as patient or health care provider behavior.
2. State Department of Health (DOH), and state professional licensing laws
   Nufactor, like many infusion pharmacies, provides care nationally. State laws govern standards surrounding biological products. In addition to following the package inserts for individual brands, strict standards are enacted through legislation to ensure that infection control measures are in place at every level of the dispensing process.
   Fulfillment of educational programs are mandated throughout pharmacy and nursing school training as well as upon license renewal.
   Periodic DOH inspections are done to assure that safeguards remain in place to address deficits should they arise.
3. Centers for Disease Control and Prevention (CDC) guidelines
   While each individual state is ultimately charged with the facilitation of infection control policy, the federal government must be pulled into crisis situations. To be prepared for national and global pathological events, the CDC has established guidelines for a call-to-action, to lead the nation in the development of enhanced infection control measures, utilizing federal funds when needed.
   The CDC, through presidential executive orders and the Defense Production Act can distribute aid in the form of supplies and manpower to regions most effected or vulnerable. These actions are also facilitated by the CDC Director and other scientists using clinical data to drive sound policies at the individual state level.
   Nufactor follows CDC guidelines when developing and initiating infection control safeguards
4. Collaborate and troubleshoot breaks in infection control when identified
   Nufactor evaluates the effectiveness of all infection control techniques on a regular basis. In addition to the patients considered most at risk by their disorder or drug therapy regimen (primary and secondary immune deficient disorders, and those on monoclonal antibody therapies), every patient must be studied for potential infection control breaches. This outcome data will be used as part of an ongoing Process Improvement program.
   

3. Adapt:

Data collection without action is of no value. Nufactor uses all available tools at our disposal to collaborate and institute change as needed. Infection control starts the moment an employee or visitor enters a Nufactor facility. Caution is exercised at every potential point of contact including administrative offices. Thoughtful infection prevention strategies are exercised in every Nufactor infusion pharmacy workspace as well as in the home by nurses seeing our patients.

1. Supplies
   Each Nufactor patient shipment provides ample supplies for patients and nurses to adhere to both intellectual and physical infection control measures. PPE is dispensed for patients and nurses alike as prudent (see also COVID-19 section).
   Periodic changes to supply lists are made as new or improved medical supplies become available and are warranted based-on data-driven metrics. Special adaptations must be made to address real or perceived threats. Supplies may be discussed with Nufactor Client Service Specialist, nurse or pharmacist.
2. Education techniques
   Educational materials have been developed for patients, as well as pharmacists and nurses. Handwashing techniques and aseptic techniques are highlighted in all Nufactor training brochures, digital and telephonic nursing communication, patient and RN webinar and RN CE programs.
   Nursing professionals can access many of these tools on the Nufactor website (nufactor.com) or by requesting them info4contractednurses@nufactor.com. Nufactor Infusion Nursing Notes offers multiple blog topics as well as CE credited programs for nurses. Patients are provided manufacturer-developed brand-specific learning materials as well when available
3. Research and surveillance
   As new information becomes available, Nufactor utilizes a clinical review process to facilitate communication across all levels of our clinical team. Clinical Senior Management plays an integral part in the decision-making process as new infection control measures are idealized, created and distributed.
   Nufactor takes pride in evidence-based methodology in the development of all education materials; infection control is an integral component of this process. Our clinical staff contributes to this process through research as well as by staying current with Standards of Practice and specialized certification programs. We refer to the Infusion Nurse Society (INS), Immunoglobulin National Society (IgNS), The Joint Commission (TJC), URAC, peer-review publications, DOH, and CDC when discussing and initiating best-practice policy implementation surrounding infection control.

A word about COVID-19 Pandemic specific accommodations:

Any global health crisis has the capacity to turn health care upside down; the COVID-19 Pandemic has exposed our collective weaknesses. We have been challenged to be malleable. As the CDC and local DOH advisers react and adapt, so too must the home infusion industry. It should be noted, that this section in and of itself is a moving target. Infection control guidelines initiated by the World Health Organization (WHO), CDC and DOH change daily at times, in response to rates of infection, hospitalization and vaccination; as an industry, we must also adapt in our efforts.

Screening both patients and nurses is a necessary strategy. Pre-pandemic, RNs seeing Nufactor patients in the home were advised to call our pharmacy team for any patient fever of 100.5 degrees Fahrenheit or greater. Today, any patient temperature elevation may be of concern for COVID-19 infection. Fever and many other symptoms could also be attributed to the biological products infused, which could cause additional confusion in screening processes. Home infusion RNs must self-report if they experience such infection symptoms themselves.

Nufactor will provide a COVID-screening tool to be used prior to seeing our patients. Please use this link to access it. Periodic updates are made as the CDC changes its' recommendations. Please review our website or the CDC website for updates regularly.

Individual belief-systems and political affiliations have contributed to this difficulty. In addition, patients who are dependent on their plasma-derived therapies are not always fully transparent about real or potential exposures to COVID-19 as they are fearful about delaying the administration of their medications.

For these reasons, Nufactor evaluates individual patients as a team effort. Communication is paramount between all employees, nursing entities and patients. Infection control modifications at times lead to delays in the timely delivery and administration of therapies. RNs directly responsible for infusing patients are on the front lines; we must protect ourselves as well as our patients. In addition to following CDC guidelines, Nufactor will coordinate with all nursing agencies and RNs to provide PPE for both patients and nurses, arrange virtual patient visits as licensing laws allow, evaluate the effectiveness of our efforts, all while maintaining HIPPA protections for patients and RNs alike.

Some individual nursing agencies have developed "COVID Teams" to minimize risk. Initially, nurses were separated by risk for serious COVID illness (age and medical conditions) vs those less at risk. Later as RNs contracted COVID and developed antibodies, they were used in homes where patients and/or family members were themselves front-line workers or potentially COVID-exposed.

COVID vaccines have drastically decreased COVID positivity rates and episodes of serious COVID-related illness. This has increased the availability of RN staffing in the home. When possible, as determined by individual circumstances, being vaccinated for COVID will go a long way in assuring the timely infusion of the life-enhancing medications prescribed to our patients.

Nufactor currently has a mandatory face mask policy for nurses, patients, and anyone physically present in the immediate home infusion environment, regardless of vaccination status. As data collection continues, we understand that COVID-vaccinated people may both transmit or contract COVID, despite vaccination. We understand that serious illness is not likely in the vaccinated population, however everyone should continue to minimize any potential transmission; especially considering COVID-variant(s) emergence.

As discussed, adherence to infection control measures is critical, especially so during a pandemic. We thank you for continued pursuit of education and review, as well as for your professionalism.