By Karen Hoffmann, RN, MS, CIC
Modern hospital infectioncontrol programs first began in the 1950s in England, where the primary focus of theseprograms 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 CommunicableDisease Center, later to be renamed the Centers for Disease Control and Prevention (CDC),began the first training courses specifically about infection control and surveillance. In1969, the Joint Commission for Accreditation of Hospitals--later to become the JointCommission on Accreditation of Healthcare Organizations (JCAHO)--first required hospitalsto have organized infection control committees and isolation facilities.
In the 1970s, infection control underwent a growth spurt. In 1970, fewer than 10% of UShospitals had an infection control program. By 1976, more than 50% of US hospitals had aversion of an infection control program, including trained nurses to perform activesurveillance. In 1972, the Hospital Infections Branch at the CDC was formed and theAssociation for Practitioners in Infection Control was organized. By the close of thedecade, the first CDC guidelines were written to answer frequently asked questions andestablish consistent practice.
Infection control underwent a midlife crisis in the early 1980s. The cost value ofinfection control programs (e.g., surveillance) was questioned. Then in 1983, acombination of factors affecting healthcare impacted common infection control practice.The first was the adoption of a fixed-price prospective payment system based ondiagnostic-related groups (DRGs), which resulted in widespread cost-containmentinitiatives to non-revenue producing hospital services. Infection control was oftenincluded. Quickly it was discovered that 56% of DRGs did not allow for any complicationsor comorbidity. Further analysis demonstrated that only 5% of costs to treat nosocomialinfections would be reimbursed to hospitals. The fallout from prospective payment meantsicker patients were admitted into hospitals since less ill patients were treated on anoutpatient 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 timewas the advent of acquired immunodeficiency syndrome (AIDS). The human immunodeficiencyvirus (HIV) has taken an enormous toll in terms of loss of life and productivity. Forinfection control professionals (ICPs), HIV has been a challenge for education, riskreduction and resource utilization.
In 1985, the Study of the Efficacy of Nosocomial Infection Control (SENIC) project waspublished, validating the cost-benefit of infection control programs. Data collected in1970 and 1976-1977 suggested that one-third of all nosocomial infections could beprevented if all the following were present:
Infection control in the 1990s was influenced by the reform of the healthcare systemwhen 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 carefacility, home health/hospice, rehabilitation facilities, free-standing surgical centers,and physician office practices. A dramatic shift in patient care practices occurred asgreater than 65% of surgery cases were operated on in an outpatient setting. Issues thatwill continue to impact infection control programs into the new millennium are achallenging combination of cost and clinical factors and include decreasing reimbursement,increasing cost to treat infections, and financial impact of implementing new governmentregulations (Table 1).
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) hassurveyed ICPs approximately every five years with a task analysis to determine the scopeof practice for developing a national infection control certification exam. Resultssuggest that regardless of the structure or hierarchy of the healthcare system, today'sICP needs knowledge of epidemiology statistics, patient care practices, occupationalhealth, sterilization, disinfection, and sanitation, infectious diseases, microbiology,education and management. The major responsibilities for ICPs to oversee includesurveillance, specific environmental monitoring, continuous quality improvement,consultation, committee involvement, outbreak and isolation management, regulatorycompliance and education. To plan, coordinate, and succeed in fulfilling theseresponsibilities, many ICPs have to redefine their roles. More ICPs are becoming managersby creating multidisciplinary support teams to carry out many of the functions.
In addition to the ICP, healthcare systems should have an identified infection controlcommittee chairperson. This position is usually filled by a person who is a physician orwho has a doctoral degree. The JCAHO standards place an emphasis on documenting thespecific epidemiologic and infection control training of this individual. In largeacademic settings, a well-trained hospital epidemiologist can provide clinical andepidemiologic consultation. However, to promote open discussion, this individual shouldnot necessarily be the infection control chairperson.
In large community hospitals, infection control consultation is usually provided by aninfectious diseases specialist who is knowledgeable about appropriate drug treatment,prophylaxis and pathology but is not formally trained in epidemiology or infectioncontrol. The small community hospital often does not have an infectious disease physicianat all. In these cases, the infection control committee chairperson will usually be from aspecialty area such as pathology/laboratory, surgery or medicine. In all areas, it is theICP who must critically lead the infection control program through day-to-day activities.
The JCAHO Standards state the goal for healthcare organizations' infection controlprograms is to identify and reduce risks of infections in patients and healthcare workers.Furthermore, there must be a functioning program coordinating all activities related tosurveillance, prevention, and control of infections. Many healthcare organizations usethese 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 clinicaloutcomes using a multidisciplinary team approach.
Across the spectrum of today's healthcare, profits are decreasing. To keep healthcaresystems viable, costs must be cut to increase the profit margin. Infection controlprograms need to demonstrate their value to their organizations. Therefore, the secondgoal should be cost control and reduction. Cost strategies may target products, injuries,or nosocomial infections. The infection control professional must examine clinicalpractices with unproven value for infection prevention and control in patients or staff.Activities that do not add value should be eliminated. ICPs should standardize productselection when at all possible. Cost savings and reductions should be integrated intoreports: the goal is to balance quality and costs.
Goals of the infection control program need to be incorporated into the missionstatement of the facility. A mission statement should tell who you are, what you do, andshould communicate a clear view of purpose and set a strategy for accomplishing the goals.The University of North Carolina Healthcare System Infection Control Program missionstatement is as follows: "Hospital Epidemiology is a department with expertise ininfection control and related disciplines. Our mission is to promote a healthy and safeenvironment by preventing transmission of infectious agents among patients, staff andvisitors. This will be accomplished in an efficient and cost effective manner by acontinual assessment and modification of our services based on regulations, standards,scientific studies, internal evaluations and guidelines." The mission statementshould communicate why we are in the business of healthcare epidemiology and infectioncontrol.
Today, infection control is well established in the US Most healthcare organizationshave had an existing infection control program. The challenge then is not developing aninfection control program anew, but a more difficult task of reorganizing an existingprogram.
The first step should be to make an assessment of the current infection controlprogram. This review will have to include any new customers for your service resultingfrom any mergers and acquisition (e.g., home health, physician offices practices,ambulatory care surgical centers) involving the healthcare organizations. ICPs shouldassess the infection control program for compliance with written standards and guidelines,areas that need improvement and available resources. ICPs can begin by systematicallyreviewing the most current regulatory standards and guidelines.
Review standards from regulatory agencies (e.g., JCAHO, Occupational Health andSafety Administration [OSHA], and Healthcare Financing Administration [HCFA], long-termcare and state health department) to ensure compliance with requirements for accreditationor licensure. Make lists of any practices that the institutional policy is not incompliance with. The current JCAHO standards require an evaluation of virtually every areaof 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--areconsidered standards of care by regulatory surveyors. These guidelines should be followedunless newer literature provides scientific rational for not using them. ICPs should besure that they are using the most current guidelines available. The Internet is useful forthis 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 andareas for improvement. An internal resource may be a well-trained certified ICP or atrained epidemiologist with funding to provide consultation to the infection controlprogram. An external resource could be a microbiology laboratory capable of rapidtuberculosis identification. An internal self-assessment of needs might evaluate previousquality improvement projects, surveillance data, or relevant sentinel events. Externalneeds may be assessed by surveys or questionnaires of hospital staff or patientsatisfaction. The value of making assessments is to be able to prioritize the greatestneeds to determine the necessary resources. From that information, an infection controlplan can be developed.
Personnel Job Description
Infection Control Plan
General Organizational Policies
Communicable Disease ReportingEducation Departmental Policies and Procedures
Every infection control program should develop a well-defined written plan outliningthe organizational philosophy regarding infection prevention and control. The plan shouldtake into account the goals, mission statement, and an assessment of the infection controlprogram. It should include a statement of authority, and should review patientdemographics including geographic locations of patients served by the healthcare system.The scope of responsibilities for actions to be taken to accomplish the goals should beincluded in this plan. Data, if available, should always drive the plan. This plan isoften referred to as the quality improvement (QI) infection control (IC) plan and shouldbe reviewed and revised annually. Each revision should include defining the objectives ofthe goals, with due dates and responsible parties (Table 2).
The key to ongoing monitoring is surveillance for nosocomial infections. Varioustechniques for surveillance have been described and evaluated including total housesurveillance, targeted surveillance, Kardex, or laboratory-based. Many ICPs have becomedisenchanted with hospital-wide surveillance and question the value of generating datawithout measurable changes. Haley, borrowing from the business world, suggested a conceptof surveillance-by-objective that selects a different surveillance strategy for differentsites of infection. Surveillance-by-objective allowed the ICPs more time for otherresponsibilities and provided a method for setting measurable goals for the reduction ofinfections.
ICPs should evaluate their institutional needs and develop a surveillance plan topresent to the infection control committee on a yearly basis. Choosing one or two specificsurveillance 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 isthe approximately 300 hospitals voluntarily reporting to the CDC's National NosocomialInfections Surveillance (NNIS) system. The definition of nosocomial infections used forsurveillance purposes needs to be uniform. The plan should discuss a system forevaluating, reporting, and maintaining records of nosocomial infections. It shoulddescribe how infection control issues requiring follow-up are identified, reported,discussed and resolved. The ICP needs the assistance of a multidisciplinary team todevelop and accomplish the surveillance plan.
Unlike scheduled activities, occasional clusters of patients who are colonized orinfected will trigger further investigation including a case-control study. New laboratorymethods developed and refined within the last decade can now determine how related thestrain is at the molecular level. The QI/IC plan should include special problem-focusedstudies that describe personnel or environmental sampling, including what circumstancesand who has the authority to order. An event such as a confirmed case or two of nosocomiallegionella or aspergillus might result in water or air sampling, respectively. A group ofpatients linked epidemiologically by time and space with multiply-resistant bacteriashould be further analyzed for evidence of cross transmission. The availability andspecificity of testing systems have made epidemiologic typing a standard tool ofnosocomial outbreaks.
The institution usually makes the infection control program responsible for reportingcommunicable diseases required by state law. ICPs need to plan on interacting with localand state health departments regarding exposure that may need immediate communityfollow-up (e.g., tuberculosis, pertussis). ICPs should assist the health departmentin confirming cases that may have been seen in the hospital or clinic.
Education programs for employees and volunteers are one method to ensure competentinfection control practices. It is a unique challenge since employees represent a widerange of expertise and educational background. The ICP must become knowledgeable in adulteducation principles and use educational tools and techniques that will motivate andsustain behavioral change. Much has been written about the education of healthcare workers(HCWs). Some of the tools used to educate HCWs successfully include newsletter, postersand videos. Technological advances in communication make video conferencing and telephoneconferences an opportunity for collaboration in teaching with few boundaries. Infectioncontrol programs must maintain training records of employees. The minimum trainingrequired is annual OSHA bloodborne pathogen, tuberculosis prevention and control and newemployee orientation.
ICPs need to attend a basic infection control-training course that is available throughAPIC, several university-based programs, or area APIC chapters. Other continuing educationoptions are available through the two professional organizations--APIC and SHEA--that haveannual educational conferences. Additionally, local APIC chapters offer educationalconferences. Locally, ICPs can participate in infectious disease or grand rounds at areahospitals. Courses on educating adults, computer technology and epidemiology andstatistics may be available at local colleges.
ICPs must oversee the ongoing review and evaluation of written policies and proceduresoutlining prevention and control mechanisms in all patient care and service areas. Thepolicies and procedures should be based on recognized guidelines and applicable laws andregulations. The policies should address the prevention of infection transmission amongpatients, employees, medical staff, contractors, volunteers, visitors, and environmentalissues. Policies must be reviewed and approved within a three-year period-with theexception of bloodborne pathogens and tuberculosis control plans, which are reviewedannually. The infection control manual must reflect what is actual practice in theinstitution because the organization is legally accountable for complying with its ownpolicies.
Some quality control measures are mandated by regulatory agencies. JCAHO expectsongoing antibiotic utilization audits. ICPs should monitor antibiotic use throughutilization studies focusing studies on high cost, high risk, or high volume antibioticusage. Actions relative to the findings from these studies should be coordinated with thepharmacy and medical staffs.
Information obtained from surveillance, laboratory cultures, or screening forepidemiologically-important pathogens must be used to ensure that appropriate isolation isinstituted. The ICP should be identified as the expert consultant on control andprevention of communicable diseases and then should have the administrative power toisolate patients. The infection control program should communicate with staff and visitorsregarding the importance of compliance in preventing secondary cases of communicablediseases and preventing device-related infections. A major challenge for infection controlprograms is to obtain compliance from the healthcare team to consistently follow isolationpolicies. The ICP should monitor the effectiveness of the isolation strategy used in theinstitution and recommend policy changes when needed.
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 theofficial route for informing hospital administration of infection control problems andaccomplishments, such as outbreak investigations, new federal or state regulations, policyand procedures compliance and routine data monitoring. The hospital's occupational healthservice has a role that significantly overlaps with the ICP. The occupational health nurseshould report the employee immunization rate, routine communicable disease screening,outbreaks of employee illness, and post-exposure evaluations at least quarterly to theICC. The ICP should provide consultation on other institutional committees so thatadministration is aware of the potential infection risks of new products or equipment (i.e.,Product Evaluation Committee) or procedures (i.e., Nursing Procedure Committee andSafety Committee).
The ICP can also expect to be called upon on a daily basis to provide consultation on awide variety of patient care issues. Therefore, collecting and maintaining updatedinfection control references and guidelines reflecting scientifically-based practices andcurrent standards is essential. Despite time constrains, it is important for the ICP toschedule time for regular reviewing of new information. One way to accomplish this is witha journal club during which scientific articles and new guidelines are criticallyreviewed.
Increasingly, infection control programs have faced overwhelming demands from multipleregulatory authorities. In 1991, the OSHA "Occupational Exposure to BloodbornePathogens (BBP) Final Rule" was passed, and in 1999 OSHA published a new BBPcompliance 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 inHealthcare Facilities" with a respiratory protection edict, which resulted inenormous costs. The final tuberculosis rule is still in the process for approval but whenpublished will require even more environmental and personnel monitoring. JCAHO hasredesigned their standards seeking outcome-oriented or performance improvementmeasurements. The Federal Drug Administration (FDA) passed new regulations in August 2000to regulate reprocessed single-use medical devices in Guidance on Enforcement Prioritiesfor Single-Use Devices Reprocessed by Third Parties and Hospitals. This documentstipulates that reprocessed devices will have to meet the same requirements of newlymanufactured devices. Therefore, hospitals and other third-party reprocessors who processthese devices for reuse will have to follow the same requirements as the initialmanufacturer.
CDC with the Hospital Infection Control Practices Advisory Committee (HICPAC) hasproduced or revised several major guidelines in the past two years including, Guidelinesfor Infection Control in Healthcare Personnel, and Guidelines for Management of HealthcareWorker Exposures to HIV and Recommendations for Postexposure Prophylaxis, Guidelines forPrevention of Surgical Site Infections. APIC has developed several guidelines coveringtopics including antisepsis and handwashing, disinfection and sterilization, endoscopy,and long-term care.
In addition, each state has rules and laws for licensure, sanitation, and institutionalkitchens. Each state has communicable disease rules to protect the general public healthand medical waste laws. All of these guidelines, standards, regulations, and laws must beinterpreted and implemented for each healthcare organization--regardless of the size--toprevent citation, fines, litigation, or negative publicity.
Significant trends in healthcare are occurring everyday including new medicalprocedures (i.e., gene therapy), new technology (multi-purpose intravenouscatheters), and a shift from inpatient to outpatient care. Further changes inreimbursement and the push to reduce the cost of healthcare services with cuts inMedicaid/Medicare and managed care reimbursements mean even less money is available forhealthcare. Survival of infection control programs will depend on whether ICPs canefficiently demonstrate and communicate their value and provide competent and effectiveservices. JCAHO standards have resulted in a dispersion of responsibility, but the ICPwithin the infection control program will remain the facilitator for the broad scope ofpractice to prevent and control infections throughout healthcare system.
Karen K. Hoffmann, RN, MS CIC, is the Associate Director of the Statewide Programfor Infection Control and Epidemiology and Clinical Instructor in the division ofInfectious Diseases at the University of North Carolina at Chapel Hill School of Medicine.Her responsibilities include education, research, and consulting to healthcareinstitutions throughout North Carolina.