Fall Infection Control Newsletter

InCo & Associates Quarterly Newsletter

Fall marks the beginning of the Influenza season. For long-term care facilities this signifies numerous flu shots for residents and staff members. Influenza is a common respiratory illness affecting thousands of people worldwide each year. Unfortunately, influenza may be lethal for individuals over the age of 65. Therefore, annual influenza vaccination for individuals over 65 and other residents of long-term care facilities is highly advised.

Individuals infected with the virus may develop body aches, headache, sore throat, sudden fever, chills, and a non-productive cough. For older residents, serious respiratory complications may develop, including pneumonia. Residents with chronic respiratory illnesses, chronic heart disease, kidney failure, and diabetes mellitus are at high risks of serious complications or death. Influenza is transmitted through respiratory droplets and contaminated items. Therefore, if resident s exhibit symptoms of influenza, they should be kept in their room until symptoms subside. Otherwise an influenza outbreak may occur. Staff members working with ill residents should wear appropriate PPEs and increase handwashing to minimize transmission. Vaccination must be administered prior to infection. Antibodies are produced 1-2 weeks after receiving the vaccination. Therefore, individuals exposed to influenza during this 1-2 week interval are not protected. Individuals who are allergic to eggs or who have developed allergic responses to the vaccine in the past should not be vaccinated. Most facilities have policies and procedures regarding the annual influenza vaccination program. Residents may consent to annual vaccinations as part of the conditions of admission.

Influenza Returns
Bloodborne Pathogens Exposure Control Plan (BBP ECP)

OSHA enacted the Bloodborne Pathogens Exposure Control Standard (29CFR 1910.1030) “to reduce occupational exposure to Hepatitis B (HBV), Hepatitis C (HCV), HIV and other bloodborne pathogens” that employees may encounter while performing their job. The Exposure Control Plan (ECP) outlines methods to protect employees from the health hazards associated with BBP and to provide appropriate treatment and counseling in the event of an occupational exposure (I.e. needlestick). The ECP is extremely detailed and outlines the responsibility of specific administrative personnel in the facility. Personnel could include Nursing Supervisors, Employee Health Nurses, Directors of Nursing, Education/Training Instructors and the employees of the facility Influenza vaccination rates among healthcare workers need improvement. Sadly, the staff members who work closest with residents are often the ones who refuse vaccination. Many staff members insist the vaccine will make them sick or mistakenly believe it is unnecessary. Influenza vaccination cannot cause the flu because modern influenza vaccines contain only inactivated viruses.

“Healthcare workers and their employers have a duty to actively promote, implement and comply with influenza immunization recommendations in order to decrease the risk of infection and complications in the vulnerable populations they care for.”

Transmission of influenza between HCWs and vulnerable residents results in significant morbidity and mortality. In a British study, 59% of HCWs with serological evidence of recent influenza infection did not recall having influenza. This suggests that many HCWs experience a sub-clinical infection and potentially transmitted influenza to the residents they cared for.

“The refusal of HCWs to be immunized implies failure on their part in their duty of care to their residents.”

For healthy adults, influenza may be an inconvenience. For the geriatric population, however, influenza may ultimately cause death. Vaccination of HCWs in healthcare facilities has been shown to significantly reduce total patient mortality. Also, effective influenza vaccination programs equate to cost savings for the employer. An influenza outbreak may cost upward of $80,000 to manage. The negative publicity may also cause further problems for the facility long after the outbreak is controlled.

HCWs have an ethical and professional responsibility to protect their residents. Influenza vaccination is one way to fulfill this duty.

“Influenza vaccination cannot cause the flu because the influenza vaccine does not contain live viruses.”

Department of Labor OSHA. Final Rule 29 CFR 1910.1030, January 2001.
InCo & Associates Infection Control Policies and Procedures Manual Bloodborne Pathogens Exposure Control Plan.

Sources: Statement on Influenza Vaccination for the 2002-2003 Season. Canada Communicable Disease Report Vol. 28. 1 August 2002.
Influenza Vaccination in Older People. Centre for Reviews and Dissemination, The University of New York. Vol 2, Issue 1, October 1996.


Urosepsis Vs. UTI: The Confusion Begins

All too often a physician will list a diagnosis of urosepsis. This causes confusion among nursing staff, Infection Control Practitioners (ICPs) and Medical Records personnel. The term urosepsis means different things to different people. “There is a division among physicians themselves as to what the term urosepsis means.”

Literally Uro relates to the urinary tract and sepsis refers to an infection, therefore urosepsis would literally mean an infection of the urinary tract or UTI. However, some physicians were trained to define urosepsis as an infection of the urinary tract that progressed into a systemic infection of the bloodstream. Perhaps this is attributed to the fact that many physicians use the terms sepsis and septicemia interchangeably as well. Again, sepsis, per se, literally means infection and septicemia refers to an “extremely complex disease process leading to progressive multiple organ failure” and death if untreated. While the two definitions have similarities, the treatment for each would vary considerably. Obviously a patient with a systemic infection would present with more severe symptoms and require more aggressive treatment. This equates to a higher level of care and acuity issues, which affect reimbursement. This is the area at which Medical Records becomes involved. The facilities’ Coders have an enormous responsibility to accurately code according to the supporting documentation found in the chart. Failure to do so may result in stiff penalties and charges of fraudulent practices.

“The Office of Inspector General (OIG) is conducting ongoing initiatives on DRGs, including DRG 416 Septicemia.”

The OIG is benchmarking data particularly for healthcare providers and facilities that have abnormally high DRG 416.

“CMS mandates that all medical conditions evaluated, monitored or treated should be reported/coded. DRG and code assignments must be consistent with AHA (American Hospital Association) and CMS regulations. Presently, Medicare has a program in place to help assure accurate DRG assignment referred to as PEEP (Payment Error Prevention Program).”

UTI coded as 599.0 with a DRG 320 could receive payment of $4,861.92. However, a sepsis caused by a UTI would be coded differently and assigned a DRG 416 with a payment of $9,180.67. Sepsis increases the severity of the illness, the LOS (length of stay) and reimbursement. Improper coding may result in hundreds of thousands of dollars in potential losses. From an ICP perspective, many factors are considered in determining the infection. Often a patient will clinically present with severe fever, hypotension, tachycardia, malaise and lethargy. Upon reviewing the laboratory data, if the bacteria in the urinalysis (UA) and the bacteria in the blood cultures (BC) x 2 are identical, this would be considered a septicemia caused by a UTI. On the other hand, not all positive blood cultures mean septicemia. Therefore, physicians use their judgment by evaluating the laboratory data and the patient’s clinical picture. “It should be noted that negative or inconclusive blood culture findings do not preclude a diagnosis of septicemia in patients with clinical evidence of the condition. {…} Coders should learn to recognize the clinical picture of septicemia so as to be able to identify when the diagnosis of septicemia should be questioned.” In the event of a needlestick injury or other occupational exposure, the affected employee must receive counseling and appropriate treatment within a narrow timeframe. It is essential for the Nursing Supervisors and the Directors of Nursing to understand the procedures involved in a post-exposure. Besides stringent timeframes, legal implications are also involved with obtaining consent forms and ensuring confidentiality.
The BBP ECP should be reviewed at least annually or whenever new or modified tasks and procedures are implemented which affect occupational exposure to HCWs. As a related issue, a Hepatitis B vaccination program must be in place within healthcare facilities. Likewise, strict guidelines and timeframes are again applicable. Employees who work in high-risk occupations (I.e. nurses, laboratory staff etc.) must be offered the Hepatitis B vaccination.
Check the Infection Control Policies and Procedures manual for your individual facility.

“Bloodstream Infection from UTI (Urosepsis).” Dr. Oster ID Specialist, Scripps Clinic Medical Group San Diego, CA.
“Coding Urosepsis.” Northeast Health Care Quality Foundation.
“Coding &DRG Notes. Urosepsis.” Northeast Health Care Quality Foundation. PEEP
“Documentation and Coding of Septicemia.” Ceasar M. Limjoco, M.D.
“General Documentation Issues. UTI/UTI with Sepsis/Urosepsis.”
“Instructions for Using the DRG 416 Septicemia Review Worksheet.”


What is InCo & Associates Doing Now?
INTERNATIONAL Infection Control/Education Consultant

The summer months kept InCo & Associates occupied with new projects.
Linda Spaulding traveled throughout the state of Hawaii educating community clinics about SARS during the month of June. She performed numerous lectures and educated over 30 clinics. She also lectured at the Ilikai hotel during a conference for the hotel association.

She also published an article in Infection Control Today entitled, “SARS, It May Be Here To Stay” Copies of the article can be ordered through www.infectioncontroltoday.com
The education was sponsored by the Department of Health. The goal of the project was to prepare healthcare and hotel workers for SARS.
In July, Linda lectured on the topics of smallpox, monkeypox and SARS in her hometown of Conneaut, Ohio.
This September Linda will be a guess lecturer for the Missouri Hospital Association at their 13th Annual Conference “Essentials of an Effective Infection Control Program”. Her topic is “Education Techniques”.


October 23, 2003 InCo and Associates will be providing an all day conference at the Ala Moana Hotel. The topics will include, SARS, Smallpox, Monkeypox, Influenza, Pneumococcal, West Nile Virus, TB, Dengue Fever and How to Develop a Financial Survival Kit.

InCo and Associates feel it is very important for healthcare workers to understand how many infection diseases can affect their families. Are we financially ready to handle the diseases of the future? This will be a very exciting day. Speakers include Jolaine Hao and Linda L. Spaulding of InCo and Associates and Michael Yee from American Express.

For more information please call Linda at 282-5738.

InCo & Associates mission is to design and implement infection control programs &/or provide lectures for our clients to meet the challenges of the 21st century. We provide an opportunity to improve the quality of care by efficiently preventing and managing infections. Our knowledge is based on prevention & control measures that are scientifically based to provide quality programs. Each client’s population is unique and responds differently to preventive and therapeutic interventions; infection control practices must be individualized for each client to achieve maximum benefits of our services.

Linda L Spaulding is considered an expert in the Infection Control arena and currently works with numerous facilities throughout Hawaii, the continental United States, and Japan . Linda was awarded the 2003 National Educator of the Year Award from Infection Control Today magazine.