Developing an Infection Control Program
By Karen Hoffmann, RN, MS, CIC
Modern hospital infection control programs first began in the 1950s in England, where the primary focus of these programs was to prevent and control hospital-acquired staphylococcal outbreaks. In 1968, the American Hospital Association published "Infection Control in the Hospital," the first and only standards available for many years. At the same time, the Communicable Disease Center, later to be renamed the Centers for Disease Control and Prevention (CDC), began the first training courses specifically about infection control and surveillance. In 1969, the Joint Commission for Accreditation of Hospitals--later to become the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)--first required hospitals to have organized infection control committees and isolation facilities.
In the 1970s, infection control underwent a growth spurt. In 1970, fewer than 10% of US hospitals had an infection control program. By 1976, more than 50% of US hospitals had a version of an infection control program, including trained nurses to perform active surveillance. In 1972, the Hospital Infections Branch at the CDC was formed and the Association for Practitioners in Infection Control was organized. By the close of the decade, the first CDC guidelines were written to answer frequently asked questions and establish consistent practice.
Infection control underwent a midlife crisis in the early 1980s. The cost value of infection control programs (e.g., surveillance) was questioned. Then in 1983, a combination of factors affecting healthcare impacted common infection control practice. The first was the adoption of a fixed-price prospective payment system based on diagnostic-related groups (DRGs), which resulted in widespread cost-containment initiatives to non-revenue producing hospital services. Infection control was often included. Quickly it was discovered that 56% of DRGs did not allow for any complications or comorbidity. Further analysis demonstrated that only 5% of costs to treat nosocomial infections would be reimbursed to hospitals. The fallout from prospective payment meant sicker patients were admitted into hospitals since less ill patients were treated on an outpatient basis or discharged earlier--a trend in healthcare we continue to see today. The second and certainly most significant factor influencing infection control at the time was the advent of acquired immunodeficiency syndrome (AIDS). The human immunodeficiency virus (HIV) has taken an enormous toll in terms of loss of life and productivity. For infection control professionals (ICPs), HIV has been a challenge for education, risk reduction and resource utilization.
In 1985, the Study of the Efficacy of Nosocomial Infection Control (SENIC) project was published, validating the cost-benefit of infection control programs. Data collected in 1970 and 1976-1977 suggested that one-third of all nosocomial infections could be prevented if all the following were present:
- One infection control professional (ICP) for every 250 beds.
- An effective infection control physician.
- A program reporting infection rates back to the surgeon and those clinically involved with the infection.
- An organized hospital-wide surveillance system.
|Table 1: Infection Control Challenges of Healthcare in 2000
Infection control in the 1990s was influenced by the reform of the healthcare system when managed care networks became the preferred method for delivery of healthcare. Infection control programs had to encompass not only hospitals but also the long-term care facility, home health/hospice, rehabilitation facilities, free-standing surgical centers, and physician office practices. A dramatic shift in patient care practices occurred as greater than 65% of surgery cases were operated on in an outpatient setting. Issues that will continue to impact infection control programs into the new millennium are a challenging combination of cost and clinical factors and include decreasing reimbursement, increasing cost to treat infections, and financial impact of implementing new government regulations (Table 1).
Infection Control Team
From the beginning, ICP has been the central figure in the infection control program. The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) has surveyed ICPs approximately every five years with a task analysis to determine the scope of practice for developing a national infection control certification exam. Results suggest that regardless of the structure or hierarchy of the healthcare system, today's ICP needs knowledge of epidemiology statistics, patient care practices, occupational health, sterilization, disinfection, and sanitation, infectious diseases, microbiology, education and management. The major responsibilities for ICPs to oversee include surveillance, specific environmental monitoring, continuous quality improvement, consultation, committee involvement, outbreak and isolation management, regulatory compliance and education. To plan, coordinate, and succeed in fulfilling these responsibilities, many ICPs have to redefine their roles. More ICPs are becoming managers by creating multidisciplinary support teams to carry out many of the functions.
In addition to the ICP, healthcare systems should have an identified infection control committee chairperson. This position is usually filled by a person who is a physician or who has a doctoral degree. The JCAHO standards place an emphasis on documenting the specific epidemiologic and infection control training of this individual. In large academic settings, a well-trained hospital epidemiologist can provide clinical and epidemiologic consultation. However, to promote open discussion, this individual should not necessarily be the infection control chairperson.
In large community hospitals, infection control consultation is usually provided by an infectious diseases specialist who is knowledgeable about appropriate drug treatment, prophylaxis and pathology but is not formally trained in epidemiology or infection control. The small community hospital often does not have an infectious disease physician at all. In these cases, the infection control committee chairperson will usually be from a specialty area such as pathology/laboratory, surgery or medicine. In all areas, it is the ICP who must critically lead the infection control program through day-to-day activities.
Goals and Mission Statement
The JCAHO Standards state the goal for healthcare organizations' infection control programs is to identify and reduce risks of infections in patients and healthcare workers. Furthermore, there must be a functioning program coordinating all activities related to surveillance, prevention, and control of infections. Many healthcare organizations use these JCAHO standards as a framework upon which to build their infection control programs. The goal of an effective infection control program must be to then improve clinical outcomes using a multidisciplinary team approach.
Across the spectrum of today's healthcare, profits are decreasing. To keep healthcare systems viable, costs must be cut to increase the profit margin. Infection control programs need to demonstrate their value to their organizations. Therefore, the second goal should be cost control and reduction. Cost strategies may target products, injuries, or nosocomial infections. The infection control professional must examine clinical practices with unproven value for infection prevention and control in patients or staff. Activities that do not add value should be eliminated. ICPs should standardize product selection when at all possible. Cost savings and reductions should be integrated into reports: the goal is to balance quality and costs.
Goals of the infection control program need to be incorporated into the mission statement of the facility. A mission statement should tell who you are, what you do, and should communicate a clear view of purpose and set a strategy for accomplishing the goals. The University of North Carolina Healthcare System Infection Control Program mission statement is as follows: "Hospital Epidemiology is a department with expertise in infection control and related disciplines. Our mission is to promote a healthy and safe environment by preventing transmission of infectious agents among patients, staff and visitors. This will be accomplished in an efficient and cost effective manner by a continual assessment and modification of our services based on regulations, standards, scientific studies, internal evaluations and guidelines." The mission statement should communicate why we are in the business of healthcare epidemiology and infection control.
Assessing Infection Control Programs
Today, infection control is well established in the US Most healthcare organizations have had an existing infection control program. The challenge then is not developing an infection control program anew, but a more difficult task of reorganizing an existing program.
The first step should be to make an assessment of the current infection control program. This review will have to include any new customers for your service resulting from any mergers and acquisition (e.g., home health, physician offices practices, ambulatory care surgical centers) involving the healthcare organizations. ICPs should assess the infection control program for compliance with written standards and guidelines, areas that need improvement and available resources. ICPs can begin by systematically reviewing the most current regulatory standards and guidelines.
Review standards from regulatory agencies (e.g., JCAHO, Occupational Health and Safety Administration [OSHA], and Healthcare Financing Administration [HCFA], long-term care and state health department) to ensure compliance with requirements for accreditation or licensure. Make lists of any practices that the institutional policy is not in compliance with. The current JCAHO standards require an evaluation of virtually every area of the facility from an infection control perspective for risks, prevention and control. Guidelines written by organizations specializing in infection control (e.g., APIC, Society for Healthcare Epidemiology of America [SHEA], CDC)--although not regulatory--are considered standards of care by regulatory surveyors. These guidelines should be followed unless newer literature provides scientific rational for not using them. ICPs should be sure that they are using the most current guidelines available. The Internet is useful for this purpose. The North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) maintains a web site on the Internet with links to guidelines and recommendations, plus many infection control resources at www.unc.edu./depts/spice/.
Program assessment should be made internally and externally for available resources and areas for improvement. An internal resource may be a well-trained certified ICP or a trained epidemiologist with funding to provide consultation to the infection control program. An external resource could be a microbiology laboratory capable of rapid tuberculosis identification. An internal self-assessment of needs might evaluate previous quality improvement projects, surveillance data, or relevant sentinel events. External needs may be assessed by surveys or questionnaires of hospital staff or patient satisfaction. The value of making assessments is to be able to prioritize the greatest needs to determine the necessary resources. From that information, an infection control plan can be developed.
|Table 2: Infection Control Plan Checklist
General Organizational Policies
Communicable Disease Reporting Education Departmental Policies and Procedures
Formulating an Infection Control Plan
Every infection control program should develop a well-defined written plan outlining the organizational philosophy regarding infection prevention and control. The plan should take into account the goals, mission statement, and an assessment of the infection control program. It should include a statement of authority, and should review patient demographics including geographic locations of patients served by the healthcare system. The scope of responsibilities for actions to be taken to accomplish the goals should be included in this plan. Data, if available, should always drive the plan. This plan is often referred to as the quality improvement (QI) infection control (IC) plan and should be reviewed and revised annually. Each revision should include defining the objectives of the goals, with due dates and responsible parties (Table 2).
The key to ongoing monitoring is surveillance for nosocomial infections. Various techniques for surveillance have been described and evaluated including total house surveillance, targeted surveillance, Kardex, or laboratory-based. Many ICPs have become disenchanted with hospital-wide surveillance and question the value of generating data without measurable changes. Haley, borrowing from the business world, suggested a concept of surveillance-by-objective that selects a different surveillance strategy for different sites of infection. Surveillance-by-objective allowed the ICPs more time for other responsibilities and provided a method for setting measurable goals for the reduction of infections.
ICPs should evaluate their institutional needs and develop a surveillance plan to present to the infection control committee on a yearly basis. Choosing one or two specific surveillance problems and setting a goal for reduction will focus the efforts of the ICP. JCAHO requires documenting the rationale for selecting a specific surveillance approach, the time needed to implement the plan, and the benchmark selected for comparison. Hospitals have had primarily one basis for comparison for their nosocomial rates, which is the approximately 300 hospitals voluntarily reporting to the CDC's National Nosocomial Infections Surveillance (NNIS) system. The definition of nosocomial infections used for surveillance purposes needs to be uniform. The plan should discuss a system for evaluating, reporting, and maintaining records of nosocomial infections. It should describe how infection control issues requiring follow-up are identified, reported, discussed and resolved. The ICP needs the assistance of a multidisciplinary team to develop and accomplish the surveillance plan.
Unlike scheduled activities, occasional clusters of patients who are colonized or infected will trigger further investigation including a case-control study. New laboratory methods developed and refined within the last decade can now determine how related the strain is at the molecular level. The QI/IC plan should include special problem-focused studies that describe personnel or environmental sampling, including what circumstances and who has the authority to order. An event such as a confirmed case or two of nosocomial legionella or aspergillus might result in water or air sampling, respectively. A group of patients linked epidemiologically by time and space with multiply-resistant bacteria should be further analyzed for evidence of cross transmission. The availability and specificity of testing systems have made epidemiologic typing a standard tool of nosocomial outbreaks.
Communicable Disease Reporting
The institution usually makes the infection control program responsible for reporting communicable diseases required by state law. ICPs need to plan on interacting with local and state health departments regarding exposure that may need immediate community follow-up (e.g., tuberculosis, pertussis). ICPs should assist the health department in confirming cases that may have been seen in the hospital or clinic.
Education programs for employees and volunteers are one method to ensure competent infection control practices. It is a unique challenge since employees represent a wide range of expertise and educational background. The ICP must become knowledgeable in adult education principles and use educational tools and techniques that will motivate and sustain behavioral change. Much has been written about the education of healthcare workers (HCWs). Some of the tools used to educate HCWs successfully include newsletter, posters and videos. Technological advances in communication make video conferencing and telephone conferences an opportunity for collaboration in teaching with few boundaries. Infection control programs must maintain training records of employees. The minimum training required is annual OSHA bloodborne pathogen, tuberculosis prevention and control and new employee orientation.
ICPs need to attend a basic infection control-training course that is available through APIC, several university-based programs, or area APIC chapters. Other continuing education options are available through the two professional organizations--APIC and SHEA--that have annual educational conferences. Additionally, local APIC chapters offer educational conferences. Locally, ICPs can participate in infectious disease or grand rounds at area hospitals. Courses on educating adults, computer technology and epidemiology and statistics may be available at local colleges.
Policies and Procedures
ICPs must oversee the ongoing review and evaluation of written policies and procedures outlining prevention and control mechanisms in all patient care and service areas. The policies and procedures should be based on recognized guidelines and applicable laws and regulations. The policies should address the prevention of infection transmission among patients, employees, medical staff, contractors, volunteers, visitors, and environmental issues. Policies must be reviewed and approved within a three-year period-with the exception of bloodborne pathogens and tuberculosis control plans, which are reviewed annually. The infection control manual must reflect what is actual practice in the institution because the organization is legally accountable for complying with its own policies.
Some quality control measures are mandated by regulatory agencies. JCAHO expects ongoing antibiotic utilization audits. ICPs should monitor antibiotic use through utilization studies focusing studies on high cost, high risk, or high volume antibiotic usage. Actions relative to the findings from these studies should be coordinated with the pharmacy and medical staffs.
Information obtained from surveillance, laboratory cultures, or screening for epidemiologically-important pathogens must be used to ensure that appropriate isolation is instituted. The ICP should be identified as the expert consultant on control and prevention of communicable diseases and then should have the administrative power to isolate patients. The infection control program should communicate with staff and visitors regarding the importance of compliance in preventing secondary cases of communicable diseases and preventing device-related infections. A major challenge for infection control programs is to obtain compliance from the healthcare team to consistently follow isolation policies. The ICP should monitor the effectiveness of the isolation strategy used in the institution and recommend policy changes when needed.
Committee and Consultant Involvement
The major committee involvement for ICPs is the infection control committee (ICC) because it gives administrative power to the infection control program. The ICC is the official route for informing hospital administration of infection control problems and accomplishments, such as outbreak investigations, new federal or state regulations, policy and procedures compliance and routine data monitoring. The hospital's occupational health service has a role that significantly overlaps with the ICP. The occupational health nurse should report the employee immunization rate, routine communicable disease screening, outbreaks of employee illness, and post-exposure evaluations at least quarterly to the ICC. The ICP should provide consultation on other institutional committees so that administration is aware of the potential infection risks of new products or equipment (i.e., Product Evaluation Committee) or procedures (i.e., Nursing Procedure Committee and Safety Committee).
The ICP can also expect to be called upon on a daily basis to provide consultation on a wide variety of patient care issues. Therefore, collecting and maintaining updated infection control references and guidelines reflecting scientifically-based practices and current standards is essential. Despite time constrains, it is important for the ICP to schedule time for regular reviewing of new information. One way to accomplish this is with a journal club during which scientific articles and new guidelines are critically reviewed.
Increasingly, infection control programs have faced overwhelming demands from multiple regulatory authorities. In 1991, the OSHA "Occupational Exposure to Bloodborne Pathogens (BBP) Final Rule" was passed, and in 1999 OSHA published a new BBP compliance document that requires safety devices to prevent sharps injuries (i.e., needleless IV systems). The OSHA tuberculosis compliance document mandated the CDC "Guidelines for Preventing the Transmission of mycobacterium tuberculosis in Healthcare Facilities" with a respiratory protection edict, which resulted in enormous costs. The final tuberculosis rule is still in the process for approval but when published will require even more environmental and personnel monitoring. JCAHO has redesigned their standards seeking outcome-oriented or performance improvement measurements. The Federal Drug Administration (FDA) passed new regulations in August 2000 to regulate reprocessed single-use medical devices in Guidance on Enforcement Priorities for Single-Use Devices Reprocessed by Third Parties and Hospitals. This document stipulates that reprocessed devices will have to meet the same requirements of newly manufactured devices. Therefore, hospitals and other third-party reprocessors who process these devices for reuse will have to follow the same requirements as the initial manufacturer.
CDC with the Hospital Infection Control Practices Advisory Committee (HICPAC) has produced or revised several major guidelines in the past two years including, Guidelines for Infection Control in Healthcare Personnel, and Guidelines for Management of Healthcare Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis, Guidelines for Prevention of Surgical Site Infections. APIC has developed several guidelines covering topics including antisepsis and handwashing, disinfection and sterilization, endoscopy, and long-term care.
In addition, each state has rules and laws for licensure, sanitation, and institutional kitchens. Each state has communicable disease rules to protect the general public health and medical waste laws. All of these guidelines, standards, regulations, and laws must be interpreted and implemented for each healthcare organization--regardless of the size--to prevent citation, fines, litigation, or negative publicity.
Significant trends in healthcare are occurring everyday including new medical procedures (i.e., gene therapy), new technology (multi-purpose intravenous catheters), and a shift from inpatient to outpatient care. Further changes in reimbursement and the push to reduce the cost of healthcare services with cuts in Medicaid/Medicare and managed care reimbursements mean even less money is available for healthcare. Survival of infection control programs will depend on whether ICPs can efficiently demonstrate and communicate their value and provide competent and effective services. JCAHO standards have resulted in a dispersion of responsibility, but the ICP within the infection control program will remain the facilitator for the broad scope of practice to prevent and control infections throughout healthcare system.
Karen K. Hoffmann, RN, MS CIC, is the Associate Director of the Statewide Program for Infection Control and Epidemiology and Clinical Instructor in the division of Infectious Diseases at the University of North Carolina at Chapel Hill School of Medicine. Her responsibilities include education, research, and consulting to healthcare institutions throughout North Carolina.
- For a complete list of references, see the webpage: www.infectioncontroltoday.com