A number of studies that address the performance and viability of infection prevention and control programs agree that not only is the profession evolving, but the demands placed upon them are increasing dramatically, without commensurate increases in resources and funding. Additionally, the field has been relying upon aging recommendations on everything from staffing to preventable infections, which can hamper the profession’s ability to document and assess its value in preventing healthcare-acquired infections (HAIs).
Absent the SENIC study, which will be discussed later in this article, one of the aging papers discussing the essential infrastructure and activities of an infection control and epidemiology program is a position paper from Scheckler et al. (1998) that reflects the guidance put forth by a consensus panel from the Society for Healthcare Epidemiologists of America (SHEA). The SHEA paper established three goals for hospital infection control and prevention programs: protect the patient; protect healthcare workers (HCWs), visitors and others in the healthcare environment; and accomplish the aforementioned two goals in a cost-effective manner whenever possible. Scheckler et al. (1998) comment, “The success or failure of the infection control program is defined by its effectiveness in achieving its goals.” The goal, of course, is to prevent HAIs, and the paper outlines outcome measures infection control programs should adopt: to measure the effectiveness of procedures, policies or programs to protect patients and healthcare providers, and to determine their related economic costs.
The SHEA paper also outlines the functions of infection control and epidemiology programs – to uphold the aforementioned three goals – through the following means:
• Managing critical data and information, including surveillance of HAIs
• Setting and recommending policies and procedures
• Intervening directly to interrupt the transmission of infectious diseases
• Educating and training healthcare providers
The paper also presents a comprehensive list of recommendations to support these four main functions.
A Name Change
Even in 1998 it was clear that the directors and managers of infection prevention and control programs had their work cut out for them. Twenty years later, the Association for Professionals in Infection Control and Epidemiology (APIC) has introduced the new title of “infection preventionist” into the community’s nomenclature to signify the sweeping changes in the field, to better reflect the responsibilities of infection control practitioners, and to elevate the title overall among hospital colleagues. (For one infection preventionist’s experience, CLICK HERE.)
While infection preventionists (IPs) continue to shape their colleagues’ perceptions of what they do, they also need to focus on their program’s performance and its role as a quality improvement effort. Haas (2006) conducted a literature review to explore the state of the science for performance measurement of infection control departments since the landmark SENIC study.
As we will see, infection prevention program performance depends upon key issues such as adequate staffing and appropriate resourcing and funding. Haas (2006) summarized several key studies from her literature review that underscore this point:
• Haim et al. (1994): 48.5 percent of an ICP’s time was spent on activities that could have been performed by a clerk.
• Scheckler et al. (1998): Reiterated a staffing ratio of 1 ICP to 250 beds.
• Friedman et al. (1999): Recommend that an infection control program must be the responsibility of at least one designated person, preferably with appropriate training for the job.
• Richards et al. (2001): One ICP per 115 occupied beds was the average staffing ratio at NNIS hospitals; ICPs were spending 40 percent of their time on non-infection control activities.
• Trundle et al. (2001): ICPs were working at 130 percent utilization and that on almost half of the days studied there was a “quality gap.”
• Stevenson et al. (2004): Reported an average of 1.56 ICPs per 250 beds.
• Quattrin et al. (2004): Only 54 percent of hospitals had a designated ICP.
Haas (2006) notes, “The SENIC study remains the most thorough assessment of the relationship between infection control department activities and patient outcomes. However, the scope of infection control practice has broadened, and the healthcare delivery system has changed dramatically since that study was performed. Few new studies have assessed infection control department performance and its relationship to patient outcomes, compliance with accepted standards of patient care, or cost of care.”
Haas adds, “An important new factor that will impact IC departments is participation in mandatory reporting of HAIs. As states adopt these reporting requirements, IC departments may be at the center of greatly increased surveillance requirements with no attached funding. This may change the focus of departments to meeting the reporting requirements or may bring more resources to maintain important intervention and education activities in addition to mandatory reporting. It will be important to monitor the effects of mandatory reporting on IC department activities and resources. The growth of IC department responsibilities over the last 30 years and continuing expansion of responsibilities greatly impacts the resources available for essential infection control activities. A current assessment of infection control department resources, functions, and scope of responsibility linked to patient outcomes and cost is needed to give healthcare institutions a relevant benchmark for infection control resource needs and the return to be expected from that investment.”
Curchoe et al. (2008) report that the evolving practice of infection control even prompted the Certification Board of Infection Control and Epidemiology (CBIC) to re-examine current practices to determine if a revised certification examination or an advanced practice examination were warranted.
APIC is currently developing a new position paper on infection prevention and control program staffing recommendations, scheduled for release in early 2009. Until then, hospitals will continue to follow the guideline of one IP for every 250 occupied acute-care beds, which has been used since the findings of the Study on the Efficacy of Nosocomial Infection Control (SENIC) were reported by the Centers for Disease Control and Prevention (CDC) in 1985.
O’Boyle et al. (2002) note, “Since that time, the healthcare system, patient populations, and expectations about the work of infection prevention and control programs have changed substantially... Infection control responsibilities have expanded beyond the traditional acute care setting. Recommendations for staffing must not only consider the number of occupied beds (average daily census) but also include the scope of the program, the complexity of the healthcare facility or system, the characteristics of the patient population, and the unique or urgent needs of the facility and community.” O’Boyle et al. (2002) add, “In the years since the 1985 SENIC report, ICPs have consistently reported an increase in infection control work activities. Concurrently, many ICPs have also reported that resources for infection control staff have remained static or have been reduced.”
O’Boyle et al. (2002) used the Delphi method and a series of 10 surveys of ICPs to identify the variables associated with performance of activities required for infection prevention and control programs in a variety of healthcare settings. The researchers found that competing responsibilities and lack of adequate resources were the most frequently cited reasons for nonperformance of essential infection control tasks, and that a ratio of 0.8 to 1.0 ICP for every 100 occupied acute-care beds was considered to be adequate staffing.
The O’Boyle study brought to light several valuable trends related to job performance and practice. The researchers discovered that the greatest number of new or expanded activities occurred in the management and communication functions, and included tasks such as quality improvement, employee health, clerical tasks, and nursing education. Estimates of time spent on these additional responsibilities ranged from 5 percent to 60 percent, even as ICPs on the Delphi panel reported their main duties of identification of infectious disease processes, surveillance/epidemiologic investigations, prevention of transmission of infectious agents, and the control of transmission of infectious agents via communication and management, education and training. According to O’Boyle et al. (2002), surveillance took up the most time, followed by education, prevention, and communication activities; the least amount of time was spent on control activities. Developing policies consumed the greatest amount of time in prevention activities (20 percent), followed by analyzing information from resources (18 percent) and developing prevention strategies (18 percent). The task necessitating the greatest amount of time in the management and communication functions was compliance with regulations, such as required reporting and meeting accreditation standards (17 percent), followed by quality improvement activities (14 percent) and planning (13 percent).
O’Boyle et al. (2002) found that ICPs cited “competing responsibilities” as the biggest obstacle to performing their key duties of surveillance, epidemiologic investigations and prevention activities, while a lack of adequate resources affected their ability to perform all infection control functions. These resources included laboratory, staff, electronic medical record systems, access to infection control experts or infection control resources, adequate time for data analysis, and HCW education.
O’Boyle et al. (2002) note that infection control job responsibilities have expanded into community health outreach and system-wide activities, as well as into non-infection control responsibilities, and comment: “The former expansion may simply indicate an evolutionary change in the span of responsibility and influence of the ICP. The latter expansion of ICP responsibilities into non-infection control activities likely reflects the stressors (financial and human) within healthcare systems. Infection prevention and control are pieces of the larger healthcare mosaic and, as such, are reflecting stressors inherent in resource limitations within the larger system. The challenge for the field of infection prevention and control will be for practitioners to participate creatively in ICP role expansion in the application of traditional infection control principles to new patient care settings. In addition, the ICP will be challenged to use new technologies while continuing to identify and describe those essential infection prevention and control activities that are associated with patient safety and improved patient outcomes. The challenge also will include further delineating the influence of non-infection control responsibilities on the performance of those essential infection prevention and control activities and patient safety.”
O’Boyle and colleagues add that recommendations for infection control staffing and resources cannot be based on bed size or patient census but rather on “the scope of the program, characteristics of the patient population, techniques for applying our scientific knowledge base about prevention, and the unique and/or urgent needs of the institution and community. These recommendations must also be made in the context of the realities of the changing healthcare system, the economic pressures on all healthcare organizations, and the demographics of the workforce.”
Talbot et al. (2007) surveyed infection prevention and control practices and resources at 134 hospitals owned by the Hospital Corporation of America as a part of a national collaborative trial examining strategies to reduce the rates of VAP and central venous catheter-related bloodstream infections in ICU patients. This Infection Control Surveillance Survey (ICSS) collected details about the administration of the infection control program, infection control resources and staffing, methods used for HAI surveillance and HAI data feedback practices. The study reported that the median total number of beds was 219; the median number of ICU beds was 22. Infection control surveillance was routinely conducted at most facilities; staffing of infection control programs varied among hospitals. Of 134 facilities, 104 had only one ICP; among these ICPs, 73 held full-time positions. A single ICP (full or part time) staffed a median of 191 beds, 20 of which were ICU beds. Only 75 of the 134 facilities had an ICP who was certified in infection control and epidemiology. Talbot et al. (2007) remark that while the median ICP staffing levels in the study cohort (a ratio of 1 ICP to 191 beds) were lower than recommended by the SENIC study (1 ICP to 250 occupied beds), it did not meet the more recently proposed benchmark of 1 ICP to 102 hospital beds proposed by Friedman and Chenoweth (2001).
The lack of time, resources and manpower could be taking its toll on the infection prevention workforce. O’Boyle et al. (2002) observe, “In addition to the current staffing shortages, the healthcare system is rapidly facing a crisis of severe proportions related to the aging workforce, particularly in nursing. As is true of nursing in general, ICPs will be retiring in greater numbers during the next decade than they can be replaced. Even if healthcare organizations acknowledge that resources for infection prevention and control programs should be increased consistent with findings of this study and consensus recommendations, there is serious doubt that there will be adequate numbers of qualified ICPs to fill open positions.”
O’Boyle et al. (2002) add further, “The literature and research regarding the healthcare work climate is relatively young, but it is important to note that some comments by panel members indicated a sense of futility and resignation. Increased job demands are reported to be associated with a greater sense of stress as well as reduced job satisfaction. Panel members reported that many essential infection control tasks are not being performed. The most important question, however, is whether nonperformance of essential tasks makes a difference in patient outcome.”
Recently there have been studies conducted to examine the impact of staffing on patient outcomes. Hugonnet et al. (2007) studied a cohort of 1,883 patients totaling 10,637 patient-days (415 of which developed at least one HAI while in the ICU) and representing an overall infection rate of 64.5 episodes per 1,000 patient-days. The average 24-hour nurse-to-patient ratio was 1.9. Controlling for exposure to central venous catheters, mechanical ventilation, urinary catheters and antibiotics, the researchers found that a higher staffing level was associated with a 30-plus percent infection risk reduction, and estimated that 26.7 percent of all infections could be avoided if the nurse-to-patient ratio was maintained at 2.2 or more.
Last summer, a study from Columbia University School of Nursing researchers reported that hospitals that have better working conditions for nurses are safer for intensive care unit (ICU) patients, when measured by rates of HAIs. A review of outcomes data for more than 15,000 patients in 51 U.S. hospital ICUs showed that those with high nurse staffing levels (the average was 17 registered-nurse hours per patient day) had a lower incidence of infections. The study revealed that ICUs with higher staffing had lower incidence of central line-associated bloodstream infections, ventilator-associated pneumonia and skin ulcers.
“Nurses are the hospitals’ safety officers,” says Patricia W. Stone, PhD, MPH, R, assistant professor of nursing at Columbia University Medical Center and the study’s first author. “However, nursing units that are understaffed and that have overworked nurses are shown to have poor patient outcomes.”
To further understand the evidence related to the relationship between hospital staffing and patients’ risk of developing HAIs, Stone and colleagues (2008) audited 42 articles from the literature that examined nurse staffing; of these, just seven did not find a statistically significant association between nurse staffing variable(s) and HAI rates. The researchers did find that use of registry staff was associated with increased rates of HAI in several studies. Stone et al. (2008) note, “Although the limitations in the study designs make us unable to determine a specific evidence-based nurse staffing level benchmark that is associated with a decreased risk of HAI, trends are apparent from this body of research. For example, although only two investigators studied ventilator-associated pneumonia, both reported that patients who were cared for in an intensive care unit with lower levels of nurse staffing had an increased risk of ventilator-associated pneumonia. Although the exact mechanism for this association was not studied, it is possible that when staffing levels are reduced, the nurses are unable to provide recommended care, such as keeping the head of the patient bed elevated.”
Stone et al. (2008) add that there is a lack of evidence indicating the impact of staffing of infection control departments and availability of physicians in the prevention of HAI, and lament in general a lack of updated information since the SENIC study: “(The SENIC) study established a connection between elements of infection control programs and provided strong evidence that hospitals with more staffing and more intense infection control processes had lower rates of HAI. However, the study has not been updated, and evidence to inform current practice is seriously lacking. For example, the investigators of the original study recommended that hospitals employ at least one full-time infection control professional for every 250 occupied beds; because of the lack of more-recent data, this outdated ratio is sometimes applied as the standard today. Although this ratio may have been adequate many years ago, there have been many changes in healthcare delivery, such as shorter lengths of stay, increased patient acuity, and an increased risk of HAI, including HAI due to multiple-drug resistant organisms. Although there has been a number of reports that describe infection control staffing, no researchers have updated this study. The use of the outdated ratio may be contributing to the persistent nature of the HAI problem.”
Economic Impact of Infection Control
Making the business case for infection prevention and control to hospital administrators and other stakeholders has been quickly moving up the list of infection IPs’ priorities these days.
A session on economics and infection control presented at the 2005 meeting of the Association for Professionals in Infection Control and Epidemiology (APIC) was summarized in an AJIC article by Stone et al. (2005). Stone et al. (2005) presented a review of the literature on infection costs and showed that there will be increased pressure to establish cost-effective services – supported by evidence-based interventions — in healthcare, which by 2013 is projected to reach 18.4 percent of the U.S. gross domestic product. However, the process to determine such cost estimates is fraught with challenges. Stone et. al. (2002) conducted a review of the literature on HAI costs published from 1990 through 2000 and found that HAI costs associated with bloodstream infections, for example, ranged from $3,500 to $40,000 per survivor, due to differences in the cost-accounting methods. Stone et al. (2005) laments the lack of standardized methods of economic evaluations and suggests that ICPs and epidemiologists could use instruction on how to conduct such evaluations. Stone et al. (2005) comments, “We know that ‘money talks,’ but what many of us are still coming to grips with is that we are not as conversant in money matters as we need to be.”
Edwin C. Hedblom, an author of the Stone et al. (2005) paper, emphasizes the importance of health economics and how they can be used to demonstrate the financial and clinical value of infection control programs, and acknowledges, “As is generally recognized, resources are limited, wants and needs exceed resources, and choices must be made.” Despite cost-cutting strategies such as aggressive contracting, reducing employee benefits, and shifting costs to others, which have created some short-term savings, Hedblom advises these savings “can rarely be sustained because inflation and the increasing use of expensive technologies eventually offset the gain. Healthcare managers are consequently looking for new ways to cut costs and get more value for their money.”
Hedblom explains that some healthcare managers and clinicians are reluctant to use health economic analyses in their decision-making because of impediments such as institutional budget constraints, as well as insufficient training on how to interpret health economic data and how to translate evidence into practice. Hedblom, in Stone et al. (2005), comments, “Management clearly wants to improve patient and employee safety just as you do. In making the case for more money, however, you have to try to think like a chief financial officer. Economic research gives you the tools for more successful negotiations.”
Denise M. Murphy, another author of the Stone et al. (2005) paper, emphasizes that ICPs are critical to the task of determining how many HAIs are preventable, and remarks, “We gather morbidity and mortality data for our infection control committees, but do we share that information with those who actually decide how our resources are allocated? Probably not. Most of us need to be more proactive in seeing to it that the decision makers understand and value our work. Healthcare executives may be interested in the national impact of infection prevention and control, but they are very interested in the local impact. It is important that they know about infectious organisms and antibiotic resistance, but they are often more receptive to information on the number of beds occupied by infected patients. Unless the hospital is on a per diem reimbursement system, freeing beds for new patients is a priority. Any information about the number of excess days and costs attributable to HAIs is thus likely to be favorably received.”
Murphy adds, “As ICPs and epidemiologists, we not only add value to our workplace but also to the communities in which we live. We have the expertise and experience to provide educational and consultation services for local health departments, doctors in private practice, and home healthcare providers. We are familiar with the literature and know the dangers of multidrug-resistant organisms; we understand how to prevent infections and how to prepare for public health emergencies. It is our business, but we must do a better job of explaining it to those who influence policy and write the checks. People are suffering and dying needlessly from infections every day. With sufficient resources, there is little doubt that we can help ease the burden of infectious diseases and save many more lives.”
Research in Infection Prevention
Many experts are calling for improved academic rigor and increased research to help document the infection prevention imperative. APIC has begun to spearhead such research, first with the MRSA Prevalence Study in 2007, and the Clostridium difficile Prevalence Study in 2008. Both studies were conducted under the auspices of APIC and the APIC Research Foundation, which funds and conducts studies to answer key research questions that aim to advance the understanding and practice of infection prevention and control.
Lynch et al. (2001) comment, “Much work remains to be done within infection control ... many fundamental research questions remain unanswered in the areas of surveillance, prevention, and control of nosocomial complications. The lack of an organized and thoughtful research agenda for the future limits the focus to small questions and promotes continued fragmentation.”
Lynch et al. (2001) report that a research priorities survey from March 2000 ranked the following issues in order of importance:
1. Measuring the financial impact of complications and the cost-effectiveness of interventions
2. Studies related to improved antibiotic usage and management of antibiotic resistance
3. Improving compliance with practices known to be beneficial, including attention to staffing and components of infection prevention and control programs
4. Surveillance for nosocomial infectious and noninfectious complications across the spectrum of inpatient and outpatient care delivery
5. Assessment of prevention strategies at specific sites such as ventilator-associated pneumonia
The project panel members also advocated for:
• the application of behavioral and management sciences to achieve compliance with infection prevention policies
• the development of methods to improve the appropriateness of antimicrobial use, research on the costs associated with morbidity and mortality attributable to SSI, VAP, BSI, and UTI in current dollars
• the economic impact of nosocomial infections
• the specific components of infection prevention and control programs and staffing in healthcare institutions which are effective in reducing rates of infection
• the development of meaningful surveillance indicators for measuring nosocomial infectious and noninfectious complications in healthcare settings
Lynch et al. (2001) say that in order to address these research priorities, “research designs that use multidisciplinary research teams with strong collaborative arrangements are necessary. In addition, substantial financial support is clearly required because several of these investigations will enroll large numbers of patients and require the time commitment of talented study personnel.”
What actually happens if the research rubber hits the road? Olmsted et al. (2007) sought to better understand the barriers to translating research into practice by conducting a survey of infection control coordinators from a random sample of non-federal hospitals, as well as all Veterans Affairs Medical Centers (VAMCs). Respondents were asked about the characteristics of their infection control program, and about barriers that prevent them from implementing evidence-based recommendations for reducing HAIs. The researchers found that the average number of hospital beds per ICP was 203; 192 at VAMCs and 206 at non-VAMCs. The top three barriers VAMC ICPs listed were: not enough resources to implement recommended practices; lots of committees but no communication; and the cost prohibitions of most new recommended practices. The top three barriers listed by non-VA ICPs were: not enough resources to implement recommended practices; lack of a physician champion; and the cost prohibitions of most new recommended practices.
Olmsted et al. (2007) comment, “The SENIC study, performed three decades ago, recommended one ICP for every 250 beds and a hospital epidemiologist as critical components of an effective infection control program. While some VA and non-VA hospitals are meeting these recommendations, over 25 percent of U.S. hospitals have more than 250 beds per ICP and less than half have a hospital epidemiologist. Major barriers were similar between VA and non-Vas, with cost or resource limitations identified as a barrier for implementing prevention practices. Further understanding of organizational barriers, such as how to foster adoption in the absence of a physician champion, is needed to promote the implementation of recommended infection prevention practices.”
The issues discussed in this article and others will undoubtedly be addressed in a two-year study that aims to document the changing role of IPs. The Columbia University School of Nursing has teamed up with APIC to design a study to evaluate the effects of the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) on infection control procedures, infection rates, and changes in the roles of infection prevention staff. According to its mission statement, CHAIPI seeks to reduce and eliminate HAIs through clinical and technological innovation; the purpose of CHAIPI is to reduce unnecessary morbidity, mortality and costs associated with HAIs in California hospitals. The study hopes to assemble data to better understand what specific institutional, procedural and technological innovations can assist healthcare providers to reduce and eliminate morbidity, mortality, and the high costs associated with HAIs. The research team will compare CHAIPI and non-CHAIPI hospitals, as well as provide an overall picture of infection prevention programs in California via a pre- and post-survey design. The design will permit evaluation of changes in IPs’ roles as well as infection prevention and control programs over the next two years. This study is based on the Prevention of Nosocomial Infections and Cost-Effectiveness (P-NICE) study led by Patricia Stone, PhD. For more details, visit: http://cumc.columbia.edu/studies/pnice/chaipi/brochure.html
Curchoe R, Fabrey L and LeBlanc M. The changing role of infection prevention practice as documented by the Certification Board of Infection Control and Epidemiology practice analysis survey. Am J Infect. Control. Vol. 36, No. 4. Pages 241-249. May 2008.
Friedman C and Chenoweth C. Infection control staffing patterns. Am J Infect Control 2001; 29:130.
Haas JP. Measurement of infection control department performance: State of the science. Am J Infect Control 2006;34:543-9.
Hugonnet S et al. The effect of workload on infection risk in critically ill patients. Crit Care Med. Vol. 35. Pages 76-81. 2007.
Lynch P, Jackson M, Saint S. Research priorities project, year 2000: Establishing a direction for infection control and hospital epidemiology. Am J Infect Control 2001;29:73-8.
O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in US healthcare facilities: Delphi project. Am J Infect. Cont. Vol. 30, No. 6. Pages 321-333. October 2002. Accessed at: http://www.ajicjournal.org/article/S0196-6553(02)00011-1/fulltext
Olmsted R, Krein S, Kowalski C, Kauffman C and Saint S. Infection control programs across the U.S.: Program characteristics and barriers to translating research into practice. Am J Infect Control. Vol. 35, No. 5. Pages E103-E104. June 2007.
Scheckler WE, Brimhall D, Buck AS, Farr BM, Friedman C, Garibaldi RA, Gross PA, Harris J, Hierholzer WJ, Martone WJ, McDonald LL, and Solomon SL. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Infect Control Hosp Epidem. February 1998.
Stone PW, Hedblom EC, Murphy, and Miller SB. The economic impact of infection control: Making the business case for increased infection control resources. Am J Infect. Control. Vol. 33, No. 9, Pages 542-547. November 2005.
Stone PW, Lawrence E, Kawar LN. A systematic audit of economic evidence linking nosocomial infections and infection control interventions. Am J Infect Control. 30:145–152. 2002.
Stone PW, Pogorzelska M, Kunches L and Hirschhorn LR. Hospital staffing and healthcare-associated infections: A systematic review of the literature. CID. 2008:47.
Talbot TR, Tejedor SC, Greevy RA, Burgess H, Williams MV, Deshpande JK,
McFadden P, Weinger MB, Englebright J, Dittus RS, and Speroff T. Survey of infection control programs in a large national healthcare system. Infect Control Hosp Epidem. Vol. 28, No. 12. December 2007.
1. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol. 1985;121(2):182–205.
2. Culver DH, White JW, Emori TG, Munn VP, Hooten TP. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol. 1985;121:182–205.
3. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1996;17(1):53–80.
4. Occupational Safety and Health Administration(OSHA), USDepartment of Labor . Occupational exposure to bloodborne pathogens: final rule. Federal Register. 1991;64004–64182.
5. Friedman C, Barnette M, Buck AS, Ham R, Harris JA, Hoffman P, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. Am J Infect Control. 1999;27(5):418–430.
6. Scheckler WE, Brimhall D, Buck AS, Farr BM, Friedman C, Garibaldi RA, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol. 1998;19(2):114–124.
7. Staffing Research Advisory Committee . Minutes of Staffing Research Advisory Committee Meeting. Atlanta (GA): : Centers for Disease Control and Prevention; 1999;.
8. Bowles N. The Delphi technique. Nurs Stand. 1999;13(45):32–36.
9. Endacott R, Clifford CM, Tripp JH. Can the needs of the critically ill child be identified using scenarios? Experiences of a modified Delphi study. J Adv Nurs. 1999;30(3):665–676.
10. Bunning RL. The Delphi technique: a projection tool for serious inquiry. LaJolla (CA): : University Associates, Inc; 1979;.
11. Facione PA. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction, executive summary, the Delphi report. Millbrae (CA): : The California Academic Press; 1990;.
12. King SL. The Delphi procedure and its uses in needs assessment for instructional developers. University of Calgary Available at http://www.ucalgary.ca/UofC/faculties/EDUC/jdnowlan/shirley1.html1999;
13. Turner JG, Kolenc KM, Docken L. Job analysis 1996: infection control professional. Certification Board in Infection Control and Epidemiology, Inc, 1996 Job Analysis Committee. Am J Infect Control. 1999;27(2):145–157.
14. McArthur BJ, Pugliese G, Weinstein S, Shannon R, Lynch P, Jackson MM, et al. A national task analysis of infection control practitioners, 1982. Part one: methodology and demography. Am J Infect Control. 1984;12(2):88–95.
15. Pugliese G, McArthur BJ, Weinstein S, Shannon R, Jackson MM, Lynch P, et al. A national task analysis of infection control practitioners, 1982. Part three: the relationship between hospital size and tasks performed. Am J Infect Control. 1984;12(4):221–227.
16. Shannon R, McArthur BJ, Weinstein S, Pugliese G, Jackson MM, Lynch P, et al. A national task analysis of infection control practitioners, 1982. Part two: tasks, knowledge, and abilities for practice. Am J Infect Control. 1984;12(3):187–196.
17. Larson E, Eisenberg R, Soule BM. Validating the certification process for infection control practice. Am J Infect Control. 1988;16(5):198–205.
18. Richards C, Emori TG, Edwards J, Fridkin S, Tolson J, Gaynes R. Characteristics of hospitals and infection control professionals participating in the National Nosocomial Infections Surveillance System 1999. Am J Infect Control. 2001;29(6):400–403.
19. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med. 1999;130(2):126–130.
20. O'Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001;29(6):352–360.
21. 21 Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nurs Res. 1998;47(1):43–50.
22. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in US hospitals. Image J Nurs Sch. 1998;30(4):315–321.
23. Arnow P, Allyn PA, Nichols EM, Hill DL, Pezzlo M, Bartlett RH. Control of methicillin-resistant Staphylococcus aureus in a burn unit: role of nurse staffing. J Trauma. 1982;22(11):954–959.
24. Haley RW, Bregman DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis. 1982;145(6):875–885.
25. Vicca AF. Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. J Hosp Infect. 1999;43(2):109–113.
26. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 1996;17(3):150–158.
27. Neddleman J, Buerhaus PI, Mattke S, Stewart M, Zelvinski K. Final report: nurse staffing and patient outcomes in hospitals. US Department of Health and Human Services, Health Resources and Services Administration; February 28, 2001; Contract No. 230-99-0021.
28. Jackson M, Chiarello LA, Gaynes RP, Gerberding JL. Nurse staffing and healthcare-associated infections: proceedings from a working group meeting. Am J Infect Control. In Press.
29. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA. 2000;283(22):2948–2954.
30. Buerhaus DO, Buerhaus PI, Auerbach DI. Expanding career opportunities for women and the declining interest in nursing as a career. Nurs Econ. 2000;18:230–236.
31. Johnson JV, Hall EM, Ford DE, Mead LA, Levine DM, Wang NY, et al. The psychosocial work environment of physicians. The impact of demands and resources on job dissatisfaction and psychiatric distress in a longitudinal study of JohnsHopkinsMedicalSchool graduates. J Occup Environ Med. 1995;37(9):1151–1159.
32. Schaefer JA, Moos RH. Effects of work stressors and work climate on long-term care staff's job morale and functioning. Res Nurs Health. 1996;19(1):63–73.
33. Soule BM. The evolution of our profession: lessons from Darwin. Tenth annual Carole DeMille lecture. Am J Infect Control. 1991;19(1):45–59.