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By Kelly M. Pyrek
An increasingly complexhealthcare agenda, including tighter fiscal budgets, evolving technologicaladvancements, and higher patient acuity, is further complicating a challengingto-do list for infection control practitioners (ICPs) already struggling withincreasing regulatory standards and antimicrobial-resistant or emergingpathogens that are spreading with unprecedented speed and virulence. ICPs facenew levels of demands on their time and expertise as they look out for thewelfare of healthcare workers and patients alike.
Infection Controls Purview is Expanding
In the 2001 white paper, Infection Control and ChangingHealthcare Delivery Systems, expert William Jarvis documents the growingtransition of healthcare delivery from hospital-based, acute-care facilities tooutpatient, transitional care, long-term care, rehabilitative care, home, andprivate office settings, thus requiring stepped-up infection control andprevention efforts.
Jarvis writes, In the 1970s and 1980s, the acutecarefacility was the center of the hospital infection and infection controluniverse. Most healthcare was delivered in the acute-care setting, andoutpatient, long-term, and home care were relatively small, in number offacilities and patients. The growth of the U.S. gross domestic product (GDP) andthe proportion spent on healthcare reflect change in healthcare delivery. From1960 to 2000, the GDP grew nearly 15-fold ... at the same time, the proportionof the GDP expended on healthcare increased from 5.1 percent to 14 percent, a 41percent increase. This growth, together with the introduction of the prospectivepayment plan based on diagnostic-related groups, led to marked changes inhospitalization.
From 1975 to 1995, the number of hospitals decreased from7,126 to 6,291, the number of hospital beds decreased from 1.47 million to 1.08million, patient admissions decreased by 5 percent, hospital stay decreased by36 percent, the average length of patient stay decreased by 33 percent, and thenumber of inpatient surgical procedures decreased by 27 percent. These trendshave resulted in fewer and smaller hospitals, more and larger intensive-careunits, and greater severity of illness in the hospitalized population. At thesame time, reports of nursing shortages and downsizing of infection controldepartments have been increasing, despite the fact that nearly 2 million HAIsoccur each year. Thus, the challenge for infection control departments inacute-care settings will be to focus surveillance activities on populations athigh risk, calculate risk-adjusted rates of hospital-acquired infection, andprovide feedback to appropriate personnel so that integrated prevention programscan be implemented and interventions evaluated to ensure quality healthcare.1
Jarvis comments, Often infection control personnel are notaware of what populations of patients are being seen or what procedures arebeing performed in outpatient settings. Furthermore, no systems are in place to collect the needednumerators (infections or adverse events) and denominators (e.g., number ofpatients with central venous catheters being seen in the clinic) data.Calculating infection or adverse event rates in outpatients and reporting themto ambulatory care personnel will be useful for improving education programs forhealthcare workers, as well as the quality of patient care.1
The Evolving Role and Responsibilities of the ICP
To meet this complex healthcare agenda, many ICPs are facedwith evolving or increasing job responsibilities. In light of the aforementionedchanging healthcare delivery statistics, Jarvis writes, Increasingly,infection control personnel have been expanding their activities to includeprevention of infection and other adverse events in long-term care, home-care,and outpatient settings. If we are to prevent infections and other adverseevents associated with the delivery of healthcare in the entire spectrum of healthcare settings, we will need to expand theinfection control departments in all these settings. Jarvis adds, Becauseof their expertise in epidemiologic methods, infection control personnel canassist infection control, quality assurance, and medical-error reductionprograms in all these healthcare system components.1
Indeed, many ICPs are adding risk management, occupationalhealth, or any number of related activities to their job descriptions.
Jarvis believes that ICPs must expand their efforts to matchthe expansion of the healthcare delivery system. He notes, Enhancedadministrative support for programs to prevent infections and medical errorswill be needed if we are to reduce the risk of infection and other adverseevents and improve the quality of care in the entire spectrum of healthcaredelivery. Now, instead of the acute-care facility being the center ofthe infection control universe, the infection control department has become thecenter of the diverse healthcare delivery system.
Infection control departments will need to expand theirsurveillance of infections and adverse events, and their prevention efforts to all settings in which healthcare is delivered.1
The responsibilities of the ICP are numerous, and include:
The Importance of IC Programs
Dennis OLeary, president of the Joint Commission on theAccreditation of Healthcare Organizations (JCAHO) addressed the importance ofinfection control and prevention in comments he delivered in November 2003 at aninfection control conference addressing healthcare-acquired infections (HAIs). OLearywas discussing JCAHOs seventh National Patient Safety Goal, whose tworequirements included that by Jan. 1, 2004, all accredited organizations must bein compliance with the CDCs latest handwashing guidelines (issued Ocotber2003), and that all unanticipated deaths associated with HAIs must be managed assentinel events (since one root cause of these sentinel events is inattention tohandwashing).
In his comments, Leary underscored the need not only foreffective infection control and prevention programs, but for organizationalleadership that would support and promote an ICPs efforts. JCAHOspatient-safety goals put leaders of healthcare organizations on notice that theyare responsible for the effectiveness of their infection control programs,
according to OLeary. If infectious problems arise in theorganization and are not properly addressed, the accountability buck stops onthe leaders desk. There is now even a separate standard which requires theallocation of sufficient resources to support the infection control program. Wewill be surveying this requirement closely. In addition, leaders are alsoresponsible for assuring adequate staff training in infection control. Most areaware that in the resource-tight times that we live in, funds to support staffeducation and training are often the first to go. That is truly misguidedpriority-setting. Leaders also have the responsibility to communicate with andensure engagement of all the parties in the organizations who have a role ininfection control. That is essentially everybody. OLeary added thathealthcare organizations will be expected to have adequate numbers ofcompetent ICPs.
Making the Business Case for ICPs
With a birth in the 1950s and growth in the 1960s and 1970s(in 1970, fewer than 10 percent of U.S. hospitals had an infection controlprogram but by 1976, more than 50 percent of U.S. hospitals had them), in the1980s, hospital infection control programs underwent a midlife crisis,according to Karen Hoffmann, RN, MS, CIC, writing in the white paper, Developing an Infection Control Program.2Hoffman explains, The cost value of infection controlprograms (e.g., surveillance) was questioned. Then in 1983, a combination of factors affecting healthcareimpacted common infection control practice. The first was the adoption of afixed-price prospective payment system based on diagnostic-related groups(DRGs), which resulted in widespread cost-containment initiatives to non-revenueproducing hospital services. Infection control was often included. Quickly itwas discovered that 56 percent of DRGs did not allow for any complications orco-morbidity. Further analysis demonstrated that only 5 percent of costs totreat nosocomial infections would be reimbursed to hospitals. The fallout fromprospective payment meant sicker patients were admitted into hospitals sinceless ill patients were treated on an outpatient basis or discharged earlieratrend in healthcare we continue to see today. The second and certainly mostsignificant factor influencing infection control at the time was the advent ofacquired immunodeficiency syndrome (AIDS). The human immunodeficiency virus(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, risk reduction and resource utilization.2
In 1985, the Study of the Efficacy of Nosocomial InfectionControl (SENIC) project was published, validating the cost-benefit of infectioncontrol programs. Hoffman reports that data collected in 1970 and 1976 to 1977suggested that one-third of all nosocomial infections could be prevented if allthe following were present:
Hoffman writes,Across the spectrum of todays healthcare, profits are decreasing. To keephealthcare systems viable, costs must be cut to increase the profit margin.Infection control programs need to demonstrate their value to theirorganizations. Therefore, the second goal should be cost control and reduction. Cost strategies may target products, injuries, or nosocomialinfections. The ICP must examine clinical practices with unproven value forinfection prevention and control in patients or staff. Activities that do not add value should be eliminated. ICPs should standardize product selection when at allpossible. Cost savings and reductions should be integrated into reports: the goal is to balance quality and costs.
Hoffman continues, Significant trends in healthcare areoccurring everyday including new medical procedures, new technology, and a shiftfrom inpatient to outpatient care. Further changes in reimbursement and the push to reduce thecost of healthcare services with cuts in Medicaid/Medicare and managed-carereimbursements mean even less money is available for healthcare. Survival ofinfection control programs will depend on whether ICPs can efficientlydemonstrate and communicate their value and provide competent and effectiveservices. JCAHO standards have resulted in a dispersion of responsibility, butthe ICP within the infection control program will remain the facilitator for thebroad scope of practice to prevent and control infections throughout healthcare system.2
Jarvis writes, Infection control personnel play a criticalrole in preventing infections and medical errors. They conduct infectionsurveillance in acute-care facilities, apply standard definitions andsurveillance protocols, calculate infection rates, report these data toessential personnel, implement prevention interventions, and evaluate theirimpact. Most importantly, as the Study of the Efficacy of Infection ControlPrograms (SENIC) has documented, the infection surveillance and preventionefforts of these infection control personnel are cost-effective.1
Kathleen Arias, MS, CIC, the current president- elect of APIC,says that in 2006, resource allocation and funding for infection controlprograms will be essential. We want to emphasize to ICPs that they mustunderstand and promote the economics of their infection prevention programs,she says. ICPs must look at the economics associated with infectionprevention and control programs in terms of how they can save lives, preventmorbidity and mortality, and generate financial savings.
Getting hospital administrators to look at the costs of theprogram and the associatedcost saving, quality improvement efforts, and patient-safety efforts that a goodinfection control program can create, resource allocation will be less of aheadache.
Top Infection Control-Related Issues for 2006
Avian Influenza and Healthcare Worker Immunization Justdays after the Department of Health and Human Services (HHS) released in lateOctober 2005 the HHS Pandemic Influenza Plan, a detailed guide for how thenations healthcare system can prepare and respond to an influenza pandemic,the Association for Professionals in Infection Control (APIC) applauded thecomponents of the plan, including an emphasis on production and acquisition ofvaccine and antivirals, as well as the commitment to global surveillance.
We have worked vigorously to encourage a comprehensiveapproach to pandemic and public health preparedness that will limit thepotential human and economic loss, says Kathy Warye, executive director ofAPIC. This plan is an important first step and the appropriate level ofattention. We encourage the President to sustain this heightened focus and workwith state and local governments, the healthcare profession, private business,and the American public to resolve additional key issues. According to Warye,those issues include:
ICPs must also face the need for healthcare workervaccination against influenza. In mid-November 2005, APICs board of directors, inrecognizing the effect healthcare worker immunization has on reducing influenzaoutbreaks and associated complications, voted to endorse mandatory influenzavaccination for healthcare professionals who have direct contact with patients.
As stewards of patient safety, our nations healthcareprofessionals exemplify the axiom first do not harm, says APICpresident Sue Sebazco, RN, BS, CIC. So it concerns APIC that a mere 36percent of these professionals opt for vaccination. Even those healthcarefacilities that promote immunization through aggressive voluntary campaigns showthat 30 percent to 50 percent of healthcare workers remain unvaccinated,Sebazco adds. The facts prove that vaccination of healthcare professionalsresults in improved patient and employee safety and lessens the economic burdenof influenza-related expenditures. It is time to do more to require healthcareprofessionals to be immunized against influenza annually.
Arias comments, Ive heard the pros and cons of mandatoryHCW immunization; most people think its a great idea, and many are concernedabout the timely delivery of vaccines and antivirals. Controversy ensues becausesome dont believe that a pandemic can occur, while others say its adoomsday scenario. I think we, as ICPs, must be somewhere in between, realizingthat a pandemic is probably going to occur and preparing our facility for it asbest s we can. We dont know if its next year or the year after, buteventually we will probably experience another pandemic. With so much global travel, avian influenza can spreadquickly, like SARS did; its in one country one day and in another the next.So I think we must be realistic about addressing all of the issues thataccompany a pandemic, such as the supply chain and its ability to providemuch-needed items like masks and gowns. As soon as we have an outbreak, therewill be hoarding of supplies; we have to make plans for that.
Mandatory Reporting of HAIs
Promisingto be a big issue in 2006 is the adoption of mandatory infection reportingrequirements at the state level, and further discussion of adoption at thefederal level as well. In February 2005, the CDCs Healthcare Infection ControlPractices Advisory Committee (HICPAC) issued recommendations addressing thepublic reporting of HAIs to provide direction and assistance to those statesthat have enacted or are considering legislation to require hospitals to makeinfection rate data available to consumers. The HICPAC guidance documentrecommends that any efforts to mandate public reporting ensure the use ofestablished surveillance methods and experts in infection prevention to gather,interpret and report such information; the establishment of a multi-disciplinaryadvisory committee to provide oversight in the creation of any reporting system;the choice of appropriate process and outcome measures; and the provision offeedback to healthcare providers.
Arias says most ICPs now have a better understanding of thereporting requirements but may still be struggling with securing the additional resources that may be required for healthcarefacilities to undertake public reporting. Patrick J. Brennan, MD, chair of HICPAC, had stated about theCDC guidelines, We didnt specifically address resources but it is animportant issue. We do mention the necessity for ensuring adequate resources -we may need more infection control professionals and more information technologyresources in order to accomplish this.
We support the idea of making meaningful informationavailable to consumers, says Arias. We have dedicated our professionallives to preventing infections we just need to make sure that we do itright, so that patients have good, reliable information upon which to make sounddecisions. APIC has been concerned about the possibility that each of the 50states will adopt different reporting standards, something Warye has called adisservice to patients and healthcare institutions alike. APIC continues topush in 2006 for a national standard achieved through the consensus ofstakeholders.
In November 2005, APIC pledged $25,000 toward an infectionsreporting template that can serve as a national standard. The group committedits support to the National Quality Forum (NQF), which will develop the standardover the next 12 to 15 months in an effort to formulate consensus standards forinfection reporting via its formal Consensus Development Process. Last year,APICs board of directors called for a uniform method of collecting andreporting information on HAIs. In doing so, it supported NQFs mission toimprove American healthcare through the endorsement of consensus-based nationalstandards for measurement and public reporting of healthcare performance data.
The partnership with the National Quality Forum to assemblea consensus on requirements for mandatory reporting is a positive step forward,Arias says. We have been sending out a lot of information to the APICmembership on this, and Denise Graham has been very active in working withmembers in the states where legislation is being proposed.
We have been building discussion of mandatory reporting intonearly everything we do to get membership buy-in on the fact that thishappening, and that it is something we need to support and be an integral partof developing.
Arias adds that there is an upside to the additional workloadthat mandatory reporting requires. I think we can use the fact that mandatoryreporting is both important and required by law to make sure that infectioncontrol programs have the necessary resources they need, in terms of personnel,computer technology, administrative support, and budgetary wherewithal, to getthe job done.
(MDROs) ICPsmay be spending restless nights worrying about the onslaught of MDROs such asmethicillin-resistant Staphylococcus aureus,but they should know that a major public health initiative has been created tobattle MRSA. An interdisciplinary group of public health, industry, andinfectious disease experts has united to form the MRSA Leadership Initiative,which will focus on global prevention and management of MRSA through developmentof public and professional awareness and education programs; clinical,epidemiological and outcomes research; and projects targeted toward preventionamong high-risk patient populations.
This multi-year commitment will help get proven,life-saving improvement techniques put into action, says Denise Cardo, MD,director of the CDCs division of healthcare quality promotion. The MRSALeadership Initiative includes experts in a variety of fields, includinginfectious diseases, nursing, long-term care, pharmacy, epidemiology, medicalethics, healthcare purchasers, payers, healthcare administration, public health,and health policy. Government, physician and patient groups also will be involvedin developing and implementing programs.
MRSA incidence rates as a percentage of Staphylococcusaureus infections in many ICUs have increased from 2percent to approximately 60 percent over the past 30 years. MRSA is nowincreasing, not only in the hospital setting, but also in communities around theUnited States and the world. A recent CDC study showed MRSA infections are nowcommon outside the hospital setting and occur in otherwise healthy people. Specifically, 8 percent to 20 percent of all MRSA patientsamples examined in the study were community strains.
Early identification of an MRSA infection is key toensuring a patients successful treatment and reducing the risk of long-termcomplications of the infection, says John McGowan Jr., MD, a professor in theDepartment of Epidemiology at the Rollins School of Public Health at EmoryUniversity, and a member of the MRSA Leadership Advisory Group. The fact thatthese infections are increasingly contracted in the communities where we liveand play, in addition to the hospital, means we must become more focused andvigilant in our efforts to prevent, properly diagnose and treat them.
To that end, Arias says APIC will place much greater emphasison the word prevention when describing infection control duties. We dont do agood enough job promoting all the prevention efforts we do daily. So a lot ofthe material you will see coming out of APIC in 2006 will say infectionprevention and control. Weve been preventing infections for years, butICPs arent good at tooting their own horns. We must learn to letadministrators and consumers know how effective our infection prevention andcontrol programs are. Arias points to specific language addressing theimportance of prevention efforts approved by the APIC board in its strategicplan called APIC Vision 2012: APIC will emphasize prevention and promote zerotolerance for HAIs and other adverse events. According to Arias, It doesnt mean you have to reachzero infections, just that you will not tolerate the occurrence of HAIs.
ICPs have beenwaiting for several years for the publication of the final isolation guidelinesfrom the CDC. HICPAC has drafted guidelines for isolation precautions that wereclosed for comment in February 2005, and many hope that 2006 will be the magicalyear for their much-anticipated appearance. Arias believes some of the delay mayhave been triggered by an extended discussion of the definitions andcharacteristics of droplets and airborne spread of infectious pathogens.
Its been a real struggle with the respiratory portion ofthe draft guidelines, in terms of respirators and how to address infectiousagents that are not quite droplet and not quite airborne, like SARS, Ariassays. Nobody was really sure if SARS was spread by droplet method or if itwas truly airborne; we later learned it appeared to be spread more efficientlythan by droplet spread but is not truly airborne. Arias concedes that theprofusion of guidelines can confuse ICPs. It can be quite overwhelming,especially for new ICPs. They receive pages and pages of information in theirtraining programs, and they need to realize that this is very much a part of thejob. They just have to keep up with it.
Arias continues, One of the things we have been trying tolet new ICPs know is that APIC has a tremendous chapter network. People can use other ICPs as mentors. I tell new ICPs tointroduce themselves to someone who is already in the field, especially someonewho works in a similar healthcare organization, and work with them; this willhelp bring them up to speed. ICPs must also remember to share all of thatinformation all of the regulations, requirements, and standards withothers in their facility and in their community. The more they can set upcollaborative networks in their own circles, the more people will realize thatinfection control is a pivotal piece of the puzzle.
1. Jarvis, W.R. Infection control and changing healthcaredelivery systems. Emerg Infect Dis.7(2), 2001.
2. Hoffman, K. Developing an infection control program InfectionControl Today.