Download Requirements for Infrastructure and Essential Activities of Infection

Requirements for Infrastructure and Essential Activities of Infection Control and
Epidemiology in Hospitals: A Consensus Panel Report
Author(s): William E. Scheckler, Dennis Brimhall, Alfred S. Buck, Barry M. Farr, Candace
Friedman, Richard A. Garibaldi, Peter A. Gross, Jo-Ann Harris, Walter J. Hierholzer Jr.,
William J. Martone, Linda L. McDonald and Steven L. Solomon
Source: Infection Control and Hospital Epidemiology, Vol. 19, No. 2 (Feb., 1998), pp. 114-124
Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology
of America
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114
INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY
SHEA Position
for
Requirements
Activities
of
Infection
Hospitals:
A
February
1998
Paper
Infrastructure
and
Control
Panel
Consensus
and
Essential
in
Epidemiology
Report
William
E. Scheckler,
AlfredS. Buck,MD;BarryM.Farr,MD;Candace
MD;DennisBrimhall;
Friedman,
MPH,CIC;
Richard
A. Garibaldi,
J. Hierholzer,
MD;PeterA. Gross,MD;Jo-Ann
Harris,MD;Walter
Jr,MD;
MD
William
J. Martone,
MD;LindaL McDonald,
RN,MSPH,CIC;StevenL Solomon,
ABSTRACT
The scientificbasisfor claimsof efficacyof nosocomial
wasestablished
surveillance
andcontrolprograms
infection
bythe
Studyon the Efficacyof NosocomialInfectionControlproject.
infection
nosocomial
preanalyseshavedemonstrated
Subsequent
to be notonlyclinically
effectivebut
ventionandcontrolprograms
andprofessional
alsocost-effective.
orgaAlthoughgovernmental
nizationshavedevelopeda widevarietyof usefulrecommendationsandguidelinesforinfectioncontrol,andapartfromgeneral
of
on Accreditation
guidanceprovidedby the JointCommission
fewrecommentherearesurprisingly
Healthcare
Organizations,
forinfectionconandessentialactivities
dationson infrastructure
trolandepidemiology
programs.In April1996,the Societyfor
of Americaestablisheda consensus
HealthcareEpidemiology
and
foroptimalinfrastructure
panelto developrecommendations
ofinfection
controlandepidemiology
essentialactivities
programs
inhospitals.
Thefollowing
theconsensuspanel's
reportrepresents
ofneedsfora healthyandeffectivehospital-based
bestassessment
The recommendainfectioncontrolandepidemiology
program.
criticaldataandinformationsfallintoeightcategories:
managing
tion;settingandrecommending
complipoliciesandprocedures;
andaccreditation
ancewithregulations,
requirements;
guidelines,
of
to preventtransmission
employeehealth;directintervention
andtrainingof healthcare
infectious
workers;
diseases;education
Theconsensus
andnonpersonnel
resources.
resources;
personnel
andcategorized
recomapproach
panelused an evidence-based
of the schemedeveloped
mendations
to modifications
according
by the ClinicalAffairsCommitteeof the InfectiousDiseases
Societyof Americaand the Centersfor DiseaseControland
Prevention'sHospitalInfectionControlPracticesAdvisory
Overthe past 30 years, nosocomialinfectionsurveillance,prevention,andcontrolprogramshave been integrated intohospitalsand otherhealthcareinstitutionsto ensure
the well being of patients,staff,visitors,and others in the
healthcareenvironment.In 1958,respondingto nationwide
aureus infections
epidemics of nosocomialStaphylococcus
and recognizingthe need for hospitalsto identifyproblems
in a timely fashion, the AmericanHospitalAssociation's
AdvisoryCommitteeon InfectionsWithinHospitalsrecommended that nosocomialinfectionsurveillancebecome a
regularhospitalroutine.'In 1970,the Centersfor Disease
Controland Preventionrecommendedthat hospitalsestab-
Committee(InfectControlHospEpidemiol1998;19;114-124).
Panel.WilliamE. Scheckler,
FromtheSocietyfor Healthcare
MD,PanelChair,SHEA;Dennis
ofAmerica(SHEA)Consensus
Epidemiology
Inc (APIC);AlfredS. Buck,
andEpidemiology,
in InfectionControl
Association
forProfessionals
of Colorado
Hospital,
Brimhall,President,University
onAccreditation
MPH,CIC(APIC);
Friedman,
; BarryM Farr,MD (SHEA);Candace
MD,JointCommission
ofHealthcare
(JCAHO)
Organizations
DiseasesSocietyofAmerica(IDSA);Jo-AnnHarris,
Association
A. Garibaldi,
Richard
(AHA);PeterA. Gross,MD,Infectious
MD,American
Hospital
Practices
DiseasesSociety(PIDS);Walter
(HICPAC);
AdvisoryCommittee
Jr,MD,HospitalInfectionControl
J. Hierholzer,
MD,PediatricInfectious
Diseases(NFID);LindaL.McDonald,
MD,
William
RN,MSPH,CIC(APIC);StevenL. Solomon,
ofInfectious
J. Martone,MD,NationalFoundation
andPrevention
(HIP-CDC).
forDiseaseControl
HospitalInfections
Program,Centers
in it were
inJuly1996. Thisreportandtherecommendations
ThePanelwasinitiatedbytheBoardof SHEAin April1996 andfirstconvened
AHA,HIP-CDC,
JCAHO,
represented
bythepanelmembers:
bytheorganizations
approved
formallybytheSHEAandAPICboardsin 1997andendorsed
PIDS,IDSA,andNFID.
andEpidemiology,
in Infection
Control
1998bytheSociety
forProfessionals
ofAmericaandtheAssociation
forHealthcare
Epidemiology
Copyright
in theAmerican
Inc.Published
Journalof InfectionControl1998;26:47-60.
simultaneously
Addressreprintrequeststo the Societyfor HealthcareEpidemiologyof America, 19 Mantua Rd, Mt Royal, NJ 08061; e-mail,
[email protected].
97-SR-137.Scheckler
RA,GrossPA,HarrisJ-A,Hierholzer
WJJr,MartoneWJ,
WE,BrimhallD, BuckAS, FarrBM,FriedmanC, Garibaldi
in hospitals:
a consensus
controlandepidemiology
andessentialactivitiesofinfection
McDonald
panel
forinfrastructure
a, SolomonSL.Requirements
report.InfectControlEpidemiol1998;19:114-124.
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Vol. 19 No. 2
SHEA PosmoN PAPER
lish positionsfor an infectioncontrolnurse and a hospital
The criticalimportanceof nosocomialinfecepidemiologist.2
tions as preventableand controllableadversehospitaloutcomes was highlightedin 1976when the JointCommission
on Accreditationof Health Care Organizations(JCAHO)
publishedstandardsfor organization,surveillance,reporting, evaluation,recordmaintenance,andotherrequirements
for infectionpreventionand controlactivitiesas a condition
for hospitalaccreditation.3
The scientificbasis for claimsof
efficacyof nosocomialinfectionsurveillanceandcontrolprograms was establishedby the Study on the Efficacy of
NosocomialInfectionControl(SENIC)project,conducted
between 1974and 1983.4The SENICprojectdemonstrated
that,overall,32%of nosocomialinfectionsinvolvingthe four
majorsites (bloodstream,surgicalwound,urinarytract,and
respiratorytract) could be preventedwith high-intensity
infectionsurveillanceandcontrolprograms.
In additionto the endemic infectionson which the
SENICprojectfocused,andwhich accountfor over 95%5
of
nosocomialinfections,the medicalliteratureis repletewith
reports of epidemic infections and successful control of
them. Subsequentanalyseshave demonstratednosocomial
infectionpreventionand controlprogramsto be not only
clinicallyeffectivebut also cost-effective.6,7
Indeed,nosocomial infectionpreventionand controlprogramshave been
so successfulthatthere havebeen numerouspleasto apply
the scientificmethodologyuponwhichthese programsare
based to the more generic quality-assuranceand riskmanagementactivitiesof institutions.8This has led to the
broadeningof the use of epidemiologicaltools and principles from infection control to other areas of quality
improvementin the healthcaresetting.
The growth in infectioncontrolprogramshas been
paralleledby the establishmentand growthof a numberof
witha focuson
professionalandgovernmentalorganizations
nosocomialinfectionpreventionand control, such as the
Association for Professionals in Infection Control and
Epidemiology (APIC), the Society for Healthcare
Epidemiologyof America (SHEA),the SurgicalInfection
Society,andthe CentersforDisease ControlandPrevention
(CDC)'sHospitalInfectionsProgramand HospitalInfection
ControlPracticesAdvisoryCommittee(HICPAC).These
organizationshave used the expertiseof their membersto
developand publisha wide varietyof useful recommendations and guidelinesfor infectioncontrol.However,apart
from generalguidanceprovidedby JCAHO,there are suron infrastructure
andessenprisinglyfew recommendations
tial activitiesfor infectioncontrol programs.9,1o
Questions
then arise as to what materialand administrative
elements
areneededto ensurea successfulinfectioncontrolprogram,
what resources are needed if the traditionaldisciplineof
infection-basedhospitalepidemiologyis to be appliedsuccessfully to quality-assuranceand risk-managementprograms,and what are the criticalfunctionsthat hospitaland
healthcareepidemiologyprogramsmustundertake.
The purposeof this consensus panelwas to develop
recommendationsforthe infrastructureandessentialactivities for infectioncontrolin hospitals.
115
GOALS FOR INFECTION CONTROL
AND EPIDEMIOLOGY
There are three principalgoals for hospitalinfection
controland preventionprograms:
. Protectthe patient;
. Protectthe healthcareworker,visitors,and others
in the healthcareenvironment;
. Accomplish the previous two goals in a costeffectivemanner,wheneverpossible.
Achieving these goals is the driving force behind
every recommendationand action of the infectioncontrol
program.These goals are relevantto patient-careactivities
in any healthcaresetting where patientsare cared for, not
only in the acute-carehospitalbut also in skilled nursing
facilities,nursing homes, rehabilitationunits, urgent-care
centers, same-daysurgery facilities,ambulatory-carecenters, and home-careprograms.The goals, recommendations, andexpectedoutcomesthatfollowrepresenta single
standardof care for all hospitals.
The success or failure of the infectioncontrol program is definedby its effectivenessin achievingits goals.
The goals of the program promote actions that are
designedto limitthe spreador to preventthe occurrenceof
nosocomialinfections.It is imperativethat every healthcare institutiondevelop specific objectives and outcome
measures to determinewhetherits infectioncontrolgoals
have been achieved.This is mandatedby JCAHOandmost
state licensing or credentialingorganizations.9The outcome measures that are selected for monitoringshould
relate directlyto the specificgoals of the infectioncontrol
program,namely,
. To measure the effectiveness of procedures,
policies,or programsto protectpatients;
. To measure the effectiveness of procedures,
polcies, or programsto protecthealthcare
providers;and,
. To determine the cost-effectiveness of these
activities.
PROTECT THE PATIENT
Forpatients,the ultimatevalueof an infectioncontrol
programis measuredby lowerrates of infection;by higher
ratesof survival;by avoidanceof, or decreasein, morbidity;
by shorterperiodsof illness or hospitalconfinements;and
by more rapidreturnto good health.These are the goals of
all therapeutic interventions and prevention efforts.
However,they are particularlyrelevantto the problemof
nosocomial infections because these complicationsare,
most frequently,unanticipatedsetbacks for patients who
alreadyare compromisedby ill health and who may suffer
dire consequencesfromthe addedstress of infection.
There is a plethoraof data that correlatethe occurrence of nosocomial infections with excess morbidity,
increased mortality, and prolongation of hospital
There also is a substantialbody of literature
stays.4,6,11,12
that
effective infectioncontrol activitiesresult
confirming
in fewer infections,improvedsurvival,decreasedmorbidiEffective
ty, and shorter durationof hospitalization.4,11-14
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116
EPIDEMIOLOGY
ANDHOSPITAL
CONTROL
INFECTION
effortshavebeenshowntocausedramatcontrol
infection
uriof catheter-associated
in the incidence
ic reductions
and
infections
tract
bacteremias,
hospitalsecondary
nary
andprimary
infections,
surgical-site
pneumonias,
acquired
whoareathighriskfortheseinfecinpatients
bacteremias
includethe
of successful
interventions
tions.4Examples
thathavebeen
infections
inratesofclean-wound
reduction
orwhen
to surgeons
is provided
whenfeedback
observed
is controlled
carefulantibiotics
thetimingofperioperative
is to
control
Theprimary
programs
goalforinfection
iy.15-17
aswellas
fromthesetypesofinfections,
thepatient
protect
as a resultof conthatmightbe acquired
frominfections
whomaybe
workers
orhealthcare
tactswithotherpatients
withtransmissible
orinfected
colonized
agents.
PROTECT THE HEALTHCARE WORKER,
VISITORS, AND OTHERS IN THE
HEALTHCARE ENVIRONMENT
February1998
costs.Thisoftenis a complex
weighanyrisksorincreased
costsofthe
thatbalances
thedirectandindirect
calculation
theestimated
costsof
control
intervention
infection
against
Thecostcalculation
thatis beingprevented.
theinfection
thenewproduct,
theexpenseofpurchasing
shouldinclude
timeforeducation,
andcostsforimplementing
personnel
that
Thefinancial
costoftheinfection
orusingthedevice.
and
theexpenseofdiagnosing
is prevented
shouldinclude
theprolongation
ofhospital
theinfection,
stay,the
treating
orloss
towork,andanylong-term
return
disability
delayed
suchas patientsatisfacof life.Non-monetary
outcomes,
ethicalissues,andnegative
pubtion,legalconsiderations,
considered.
should
be
also
licity,
FUNCTIONS OF INFECTION CONTROL
AND EPIDEMIOLOGY
ofinfection
Thekeyresponsibilities
control-problem
andanalysis,intervention
collection
data
identification,
andongoing
control through
Thesecondimportant
changesinpoliciesandprocedures,
goalfortheinfection
mirrored
monitor
success-are
to
data
collection
from
of
infections
the
is
to
by the
spread
prevent
program
in quality
as "Plan-Do-Check-Act"
Healthcare
workers.
to healthcare
cyclethatoftenis applied
personnel,
patients
areaddedthespeTothesebasicactivities
thatare improvement.25
infections
areatriskforacquiring
wellaspatients,
microbiolofhealthcare
withan cialized
contact
transmitted
epidemiology,
knowledge
byairorbydirectorindirect
and
biostatisof
infectious
transmission
and
of
of
the
functions
infectedor colonized
diseases,
ogy
patient.Many
ofinfection
tothepractice
barrier tics,whichareintegral
forisolation,
controlfocuson strategies
infection
prevencontrol.
tion
and
educaworker
healthcare
case
investigation,
precautions,
and
ofinfection
control
functions
Thus,theprincipal
services,andemployeehealthprotion,immunization
are to protectthe patientand
workers healthcare
epidemiology
gramsthatare designedto protecthealthcare
of
andto ensuretheoptimal
worker
Therearemany healthcare
to infections.
fromon-the-job
operation
exposures
of
the
means
the
healthcare
been
that
have
control
of
infection
following:
by
system
programs
examples
dataandinformation,
critical
1.Managing
Onthe
workers.18'21
itshealthcare
inprotecting
successful
including
ofnosocomial
surveillance
infecofepidemic
infections;
otherhand,therealsoaremanyreports
andprocedures;
andrecommending
2.Setting
control
inwhichinfection
workers
tionsamonghealthcare
policies
the
to
3.
effortswerelacking.22
Intervening
directly interrupt transmission
ofinfectious
diseases;
workers
and
healthcare
andtraining
4.Educating
PROVIDE COST-EFFECTIVE
INFECTION CONTROL
providers.
in
functions
Additional
directand
In today'smanaged-care
mayneedto be considered
marketplace,
These
include
of
on
the
an
participating
costsof carehave impact
indirect
requirements.
competitive- light program
consultation
forantibiotic
of the healthcare
usage,26
program
systemor inamonitoring
ness,andperhapssurvival,
evaluaadvice
on
to
the
infections
Nosocomial
product
laboratory,
microbiology
hospital
prolong
frequently
hospital.
withsafetyand
ofcostlyresources,
design,coordination
openthe tion,inputintofacility
consumption
stays,increase
activities.
andresearch
of legalactionagainstthehealthcare
programs,
provider otherquality-assurance
possibility
control
infection
for
the
functions
of
on
the
a
have
and
proandthehospital, may
Tailoringspecific
impact
negative
each
healthcare
to
be
need
its
conto
healthcare
the
facility.
of
performed
by
gram
organization
marketability
transmissions
nosocomial
thatprevent
sumers.Programs
cost MANAGING CRITICAL DATA
workers
topatients
fromhealthcare
important
provide
AND INFORMATION
insurer.4,13,23,24
andthehealthcare
fortheinstitution
savings
of Developing, Implementing, and Monitoring
of employee
maintenance
health,avoidance
Similarly,
ofhealthcare Surveillance
andprevention
infection-related
absenteeism,
The mostimportant
are
conditions
unsafeworking
activityof
data-management
workerclaimsconcerning
of
nosocomisurveillance
is
the
control
infection
healthcare
for
the
and
health
programs
system
safetygoals
important
events.Surveillance
andotheradverse
alinfections
always
costsavings.
andalsomayprovide
definable
tomonitor
topre- is conducted
thatareintroduced
events,suchassurgicalandproducts
Procedures
The collection,
in a specificpopulation.
to site infections,
orlimittheirspreadhavethepotential
ventinfections
datahasbeen
surveillance
of
and
dissemination
intervention
of
care.
increasethe costs
analysis,
Therefore,
every
in theprefactor
most
be
the
to
shown
must
determine
infections
to
used
that
is
important
single
prevent
strategy
infections.4
ofnosocomial
thatthe benefitsthatmightbe gainedfromits use out- vention
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Vol.19 No.2
SHEA PosmoN PAPER
A well-designed surveillance program, based on
soundepidemiological
principles,is essentialforperforming
all of the other necessary activitiesof the infectioncontrol
program.Facilitiesmust tailorsurveillancesystems to balance the availability
of resourceswith prioritiesfor datacollection, population needs, and institutional objectives.
Traditionally,
manyprogramshave includedsurveillanceof
nosocomialinfectionsand antibiotic-resistance
patternsand
also maymonitorotheradverseoutcomes(includingnoninfectious events such as medication errors and falls).
Integratingthe infectioncontrolsurveillancesystemswithin
the frameworkof the institution'sotherquality-improvement
efforts can facilitatefunctionalcollaborationbetween and
amongprogramsworkingto improvepatientcare.
External Reporting of Infection Rates
Increasingly,healthcareinstitutionsand healthcare
providersare being asked to benchmarkor comparetheir
rates of key events to other similarinstitutions.This may
be a more complexand difficultundertakingthanis immediatelyobvious,because the rate of nosocomialinfections
may be affected by a variety of factors, some of which,
such as the underlyinghealth status of the population
served by the hospitalor health plan,are outside the control of the institution.27-29
However, ongoing monitoring
and benchmarkingof nosocomial infection rates have
been used to implement quality-improvementactivities
thathave resultedin improvedpatientoutcomes,as manifested by a lower incidence of nosocomial infections.30
Although much of the methodologyfor accuratebenchmarkingof nosocomial infection rates is under development, the use of clinicalperformanceindicatorsystems to
assess qualityis now commonplace.The need to adjustfor
case mix, severity of illness, socioeconomic status, and
other risk factors should be understood. JCAHO will
requirereportingof such dataas part of the accreditation
process beginning in 1999.All hospitals and health plans
should ensure that infectioncontrol professionals(ICPs)
and hospital epidemiologists are consulted routinely to
provideexpert guidance in the selection of indicators,in
the oversightof datacollection,and in the analysisof indicatorsthat are used for interhospitalcomparison.28
117
worksite.Policiesandproceduresshouldreflectanalysisof
applicabledata,the institution'sexperience,and a management frameworkdesigned to protectthe health and safety
of patientsand caregivers.
Informationsources to be consulted during policy
and procedure development include surveillance data;
appropriateliterature;professionalpracticeguidelinesand
standards;HICPAC,SHEA, and APIC guidelines; legal
requirements;and regulatory standardsfrom state and
local licensing bodies and federal agencies such as the
OccupationalSafety and Health Administration(OSHA),
the Food and Drug Administration,the Environmental
ProtectionAgency,and others.31,32
Compliance WithRegulations, Guidelines, and
Accreditation Requirements
All healthcareorganizationsare subjectto regulation
and oversightby variousagencies, authorities,andgovernHealthcareorganizationsare subjectto legal
ing bodies.33-38
requirements,such as licensure, as well as guidelines or
recommendationsthatdo not carrythe force of lawbut are
recognizedas standardsof care and placethe institutionat
risk of liabilityif not followed. Some nonlegislativestandards are absolute requirementsfor the continuedfunctioning of the hospital.37JCAHOstandards,for example,
are incorporatedinto some state licensing regulations,as
well as into Medicareand Medicaidregulations.
Infection control personnel are responsible for
ensuring that the hospital's administrationand management are awareof the institution'scompliancewith all legal
and accreditationstandards,as well as with other guidelines and recommendationsthat pertainto the appropriate
practiceof infectioncontrol.
EmployeeHealth
Peoplewho workin healthcaresettings are exposed
more frequently to infectious diseases. They also may
pose a risk to patients and other healthcare workers if
they develop a communicabledisease. Healthcareworkers or personnelwho work directlywith, or in close proximity to, patients have the greatest risk of exposure. In
additionto employees, this may include medical,nursing,
and other health students; volunteer workers; religious
SETTING AND RECOMMENDING POLICIES
clergy; and visitors. Facility-associatedprehospital and
AND PROCEDURES TO PREVENT
posthospitalpersonnel,such as home health care, nursing
ADVERSE EVENTS
home, clinic, day-care,funeralhome workers, and emerAssuring the Appropriatenessand Feasibility of
gency medical technicians, also should be considered as
Policies and Procedures
being at risk. The employee or occupationalhealth proPolicies and proceduresmust be based on scientifi- gram of a healthcarefacility is charged with developing
and implementingsystems for diagnosis, treatment,and
cally valid infectionpreventionand controlmeasures that
have a positiveimpacton process and preventnosocomial preventionof infectiousdiseases in healthcareworkers.It
infections.They must be practicalto implementand must
plays an important role in infection control within the
be reviewedregularlyto maintainaccuracyand validity.31 facility.18-2o
The infectioncontrolprogramand the employThey must be writtento serve as a resource for providers ee health or occupationalhealth programneed to work
responsiblefor their implementation.Policies and proce- collaborativelyto develop policies and procedures for
dures generallyare providedat two levels: (1) those that
healthcare personnel, such as placement evaluations,
are organization-wide
and applicableto all employees and
health and safety education, immunization programs,
(2) specificpolicies and proceduresapplicableto a unique
evaluationof potentiallyharmfulinfectiousexposures and
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118
ANDHOSPITAL
EPIDEMIOLOGY
INFECTION
CONTROL
implementationof appropriatepreventivemeasures, coordinationof plans for managingoutbreaksamong personnel, provision of care to personnel for work-relatedillnesses or exposures, educationregardinginfectionrisks
relatedto employmentor specialconditions,development
of guidelines for work restrictionswhen an employee has
an infectious disease, and maintenanceof health records
on all healthcareworkers.38
Many of the communicablediseases of healthcare
workers are vaccine-preventable;
appropriatevaccine use
protects both the healthcare worker and the patients.
Immunizationprograms have been found to be highly
cost-effectiveand are a criticalcomponentof the employee
health effort.18,19'38'39
INTERVENING DIRECTLY TO PREVENT
THE TRANSMISSION OF INFECTIOUS
DISEASES
OutbreakInvestigation and Control
The most common setting in which ICPs and hospital epidemiologistsmust intervene directlyin patient-care
activities is in the control of an outbreakof nosocomial
infections.An outbreakmay be defined as an increase in
the incidenceof a disease, complication,or event abovethe
backgroundrate.Thus, each healthcarefacilitymust have
baseline surveillancedata on the incidence of nosocomial
infectionsin orderto identifyoutbreaks.27
The availabilityof appropriatemicrobiologylaboratory capacityis essentialto the detectionand investigationof
outbreaks.oOutbreaksof unusualspecies of microorganisms will not be identifiedunless clinicalmicrobiologypersonnel are able to recognize that an unusualpathogenis
presentand to performappropriatemicrobiologicaltesting
to identifythe microorganism.Similarly,clusters of commonly isolated species of microorganisms(eg, S aureus,
Escherichiacoli, Pseudomonasaeruginosa) may not be
detected unless the isolates can be shown to be a single
Clinicalmicrobiologypersonnel
strainor clonalvariant.41-44
must be able to perform or obtain appropriatetesting to
make these determinations.Such findings support epidemiologicaldatapointingtowardeithera commonsource
or a linkedchainof transmission.
Appropriateclinicalspecimensmust be obtainedand
sent for culture.Infectioncontrolpersonnelshould ensure
that medicaland surgicalstaff are familiarwith the indications and the necessity for obtainingappropriatecultures
prior to initiatingantimicrobialtherapy in patients with
nosocomial infections. Microbiologylaboratoryrecords
must be kept in a mannerthatpermitsretrievalof information (preferablyfrom a computerizeddatabase)by type of
pattern, type of
microorganism,antibiotic-susceptibility
clinical specimen, ward, service, attendingphysician or
surgeon,and date the culturewas obtained.
It is imperativethatoutbreaksbe investigatedby personnel trainedin infectioncontrol,infectiousdisease epidemiology,and appliedstatisticalanalysis.Failureto appreciate the complexityof outbreaksin the healthcaresetting
can lead to nontreatmentor mistreatmentandto substantial
February1998
To investigatethe outbreak
increasesin expenditures.21,22,44
and
all
identify possible cases, infectioncontrol perfully
sonnel must have unrestrictedaccess to necessary information, including medical, nursing, and administrative
recordswithinthe institution.In an outbreaksetting, decision making must be immediate,and decisions must be
implementedexpeditiously.Access to the medical literature is crucial,and publichealth supportalso may be necessary.Therefore,it is essential that infectioncontrolpersonnel have direct access to administrative,medical, and
nursingpersonnelwith authorityto directchanges in institutionalpolicies and practicesnecessary to achieve immediate control of the outbreak.Administratorsneed to be
involvedin, and ensure adequatesupportfor,the infection
controlprogram.9
Education and Training
The preventionof nosocomialinfectionsrequiresan
organizededucationaland trainingprogramin all healthcare facilities.Ongoing educationin the area of infection
control is necessary for several reasons. All healthcare
workersneed to be awareof new scientificinnovationsin
the areaof infectioncontrol.Forexample,the properimplementationof technologicalinnovations,such as improved
personalprotectiondevices, demandslearningnew knowledge and skills. Regulatoryagencies and accreditingentities such as OSHA and JCAHO require that workers
receiveongoingtrainingin a varietyof areas,dependingon
theirjob duties.This trainingincludesinstructionon isolation precautions,asepticpractices,and preventionof blood
and body fluidexposure.38,45
Ongoing monitoring of patient-care practices is
required to identify areas of continued concern and to
assess effectiveness of educational interventions.
Through the nosocomial infection surveillanceprogram,
informationwill be availableto informhospitalpersonnel
about problems occurring in their facility. In addition,
ongoing surveillance provides both the ICP and the
healthcare worker with feedback on results of changes
instituted to address those problems. This feedback
serves as an educational tool to stimulate change in
patient-carepractices.46,47
Educationand reinforcementof policies and procedures are essential to prevent nosocomial infections.
Trainingtechniques need to be applicableto adult learning styles that will stimulatebehaviorchange. Providing
specific informationto healthcare personnel regarding
infection risk, such as reporting surgical-site infection
rates to individualsurgeons, also has been effective in
Infectioncontrol
reducing nosocomialinfectionrates.15,48
educationshouldbe simple,clear,and relevantto the policies of the healthcarefacility.Teachingformatsshould be
varied through use of individualizedprogrammededucationalunits utilizingvideo and computertechnology,faceto-face discussions with infection control personnel, and
practicaldemonstrationsin order to meet the needs of
healthcareworkerswithvaryingeducationalbackgrounds
andwork responsibilities.38,45
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Vol.19 No. 2
SHEA POSITION
PAPER
Resources
The personnel and nonpersonnel (physical)
resources for infectioncontroland epidemiologyin hospitals shouldbe proportionalto the size, sophistication,case
mix, and estimatedrisk of the populationsserved by the
institution.Institutionsmust complywith basic accreditationstandardsandthe stateandlocallicensingstandardsof
theircommunity.Coordinationand sharingof supportwith
otherquality-improvement
services shouldbe encouraged,
but not at the risk of limitingadequatebasic services for
the scientificallywell-supportedinfection control components of the process. Housingof these units at a common
geographic site within the institutionwill encourage the
communicationandcross-fertilization
thatwill enhancethe
qualityof the individualandjointprograms.
PERSONNEL
RESOURCES
119
the scope of the workof an ICEIn most acute-carehospitals
today,the scope of work of ICPsis much greaterthanthat
providedby the old ratio.
The ICP most often has been a registered nurse,
often with a bachelor's degree. Other ICPs are medical
technologists,and some may have master'sdegrees in epidemiologyor other relatedfields. ICPsoften receive training in infectionsurveillanceand controland in epidemiology throughbasic trainingcourses offered by professional
organizationsor healthcareinstitutions.Many individuals
in such positions have obtainedCertificationin Infection
Controlby the CertificationBoardof InfectionContro1.49
Less highly trained individualsare used by some
hospitals as surveillancetechnicians (eg, licensed practical nurses or medical-careassociates). With on-the-job
trainingand close supervisionby an ICP,such individuals
may function effectively in surveillance and compliance
monitoringbut may have limited abilitiesto provideeducation and consultation,especially for senior healthcare
staff;however,theirpresence providesan abilityto expand
surveillancefunctionsand frees ICPsfor additionaleducation and consultationactivities.
The Hospital Epidemiologist
Overall,SENIC,conductedby the CDC, found the
trainedhospitalepidemiologistto be an essential component of an effective hospital infection control program.4
However,SENICdidnot quantifyor specifythe typeof training forhospitalepidemiologists.Althoughmost hospitalepidemiologistsdidnothaveformaltrainingin epidemiologyat
the time of the SENICstudy,there is no questionthat such
trainingis helpful,and the increasingsophisticationof the
publishedliteraturearguesthatit is essential.Most current
hospitalepidemiologistsare clinicianswithtrainingin internal medicineor pediatricsand in infectiousdiseases. Some
pathologistswitha primaryinterestin clinicalmicrobiology
or sterilizationand disinfectionalso have been involvedin
hospital epidemiologyprograms.Increasingly,additional
trainingin epidemiologyhas been obtained. Continuing
educationin hospitalepidemiologycan be accomplishedby
readingrecentlypublishedtexts, journalssuch as Infection
Controland HospitalEpidemiology,AmericanJournal of
InfectionControl,and the Journalof HospitalInfection;by
attendingthe annualmeetingsof relevantprofessionalorganizations;or with formaltrainingin hospitalepidemiology
such as provided by the SHEA/CDC training course.
Hospitalepidemiologistsshouldbe compensatedadequatefor theirworkby the healthcarefacility
ly andappropriately
or entityutilizingtheir services.
ComputerSupport Personnel
Computersupportpersonnelare a requisitefor the
managementand analysisof the administrativeandclinical
dataof the modernhospitalandfor the hospitalepidemiology andinfectioncontrolprograms.Suchpersonnelshould
be availableto facilitateeducationin, and use of, computer
hardwareand appropriatesoftwareprograms.Healthcare
institutionsandhospitalepidemiologyprogramsshouldbe
awareof the goals of the Instituteof Medicinereport The
PatientRecord:An EssentialTechnology
Computer-Based
for
HealthCare.5o
The Infection Control Professionals and
Surveillance Personnel
The SENICstudyfoundthatICPs(formerlyknownas
infectioncontrolpractitioners),manyof them nurses,were
essentialcomponentsof an effectiveprogram.The SENIC
studysuggestedthathavingone ICPper 250 occupiedbeds
was associated with an effective program.4However,in
recentyears,the amountand complexityof the ICP'swork
has burgeoneddue to increasesin the intensityand complexityof patientcare delivered,increasedseverityof illness
of the patientpopulationat risk, and increasedactivityin
healthcaredeliverybeyondthe hospital.Therefore,the old
ratioof one ICPper 250beds is no longeradequate,because
the notionof a ratiotied to beds is now insufficientto define
NONPERSONNEL SUPPORT
Office Support
The hospitalepidemiologyand infectioncontrolprogramshouldhave sufficientoffice spaceto house members
of the program. Contiguous space with other qualityimprovementprogramswill foster interstaffcommunication, encourage development of shared programs, and
makeefficientuse of secretaries.This space shouldbe convenientto the clinicalservices undersurveillance.
In additionto standardoffice equipment,appropriate
furnishingsshould includecommunicationtools sufficient
to supportthe program.A minimalsystem would include
telephones, pagers, fax and copying services, and basic
office supplies.
Secretary
Secretarialservice is essential for the infectioncontrol program.Computerdataentry,typingof minutes,policies, and a varietyof otherdocumentsand correspondence
can be done most efficientlyby appropriatesupportstaff.
Other support and communicationfunctions, such as
answeringthe telephoneand arrangingmeetings,also are
appropriatesupportresponsibilities.
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120
INFECTIONCONTROLAND HOSPITALEPIDEMIOLOGY
ComputingSupport
A preferredsystem would include a desktop or laptop computer and a printer.Available software should
include word processing, spreadsheet,databasemanagement, and basic statisticalprograms. Many commercial
softwareprogramsare availableat modest cost. An importantconsiderationis to budgetfor sufficienttrainingso that
the software is used appropriately.For infection control
programswith extensive educationalresponsibilities,use
of a softwarefor slide preparationand programpresentation may be advantageous.Establishmentof a networkto
allow single entry, primary-sourcecapture of healthcare
data should be a strategicgoal for the efficienthandling,
analysis, and distributionof infection control and other
institutionaldatawithinthe institutionand throughoutthe
integratedhealthcaresystem.
With Internetservices availablein most areas of the
country,a modemis essentialfor access to the Internetand
from
e-mail.The abilityto contactanddownloadinformation
vast
of
the
National
the
resources
medical
libraries,
regional
Libraryof Medicine,the CDC,the FederalRegister,and the
Internetpages of professionalorganizationssuch as SHEA,
APIC,andthe InfectiousDiseases Societyof Americaare of
tremendousaddedvalueat minimalcost.
Semiautomatedbackup systems may be added at
small cost and will assist in preventingthe unfortunate
loss of criticaldatawith electricalor equipment(eg, hard
disk) failure.
February 1998
laboratories."These nonroutinetests may be essentialfor
conductingepidemiologicalor outbreakinvestigations.
ConnectingLinks and the Future
The terms infectioncontroland hospitalepidemiology
often have been used synonymously.Althoughepidemiology-the study of disease in the population-is the science that supports preventionand control efforts for all
diseases of publichealth importance,hospitalepidemiology has been limited,for the most part, to the description
and analysis of the occurrence of nosocomial infections.
However, with the increasing reliance on "health outcomes" as a measure of the quality of health services,
interest in the quantitativeassessment of patientcare and
healthcare support services has broadened. Thus, the
applicationof epidemiologyor of related statisticalmethods drawnfromindustrialprocess controlto areas outside
infectioncontrolnow has become commonplace.52-54
This consensus paperfocuses on the requirements
and activities of infection control programs in hospitals.
Although among the many changes occurring in healthcare is a markedincrease in out-of-hospital
services, such
as ambulatoryand other nonhospitalcare, the Consensus
Panel believes that the preponderanceof the risk of nosocomialinfectionsstill is found among the sickest patients,
those who will continue to occupy acute-carehospitals.
Despite shorter hospital stays and a decreasing census,
there is an increased potentialfor nosocomial infections
due to the changing demographicsof the populationand
Audio-Visual Support
new,increasinglyinvasivetechnology.Patientsin hospitals
Inserviceeducationis a vitalcomponentof infection will be sicker; there will be new antibiotic-resistant
controland epidemiologyprograms.A 35-mmslide projec- microorganisms;there will be new instrumentsand procedures;and there will be new infectiousdiseases. Thus, the
tor, an overheadprojector,and a televisionmonitorwith a
need for infectioncontrolas a specialtypracticein the hosVCRare basic resources.Newer technology,such as computer projection equipment and software support pro- pitalwill continueto increase.
Hospitalinfectioncontrol is a quality-improvement
grams,is being utilizedincreasingly.
activitythat focuses on improvingthe care of patientsand
protectingthe health of staff.53Professionalsin infection
MicrobiologyLaboratory Support
controland qualityimprovementrecognizethat the methclinifrom
patient
Microbiologylaboratoryreports
ods used in each of these fields derive from similarbasic
cal specimensshouldbe made readilyavailableto assist in
the surveillanceof nosocomialinfections.Hospitalmicro- principlesand have manycommonelements,althoughthe
implementationand applicationof the methods used by
biology laboratories should comply with the relevant
each of these disciplines may be somewhat different.
accreditingstandards.
Infectioncontrolprofessionalshave adaptedand used the
of
for
sufficient
A microbiologybudget
investigation
theories and tools of continuousqualityimprovementto
outbreaksat no chargeto the patientshouldbe availableto
focus on improvinghealthcaredelivery processes, somethe infectioncontrolprogram.4o
times with dramaticimprovementsin patientcare.54This
link between infection control and the performancePathology Services
Adequate pathology services should be available, measurementand -improvementactivitiesin a healthcare
includingmicrobiologytesting for postmorteminvestiga- facility is crucial. The epidemiological and statistical
methods used by hospitalepidemiologistsand ICPs often
tions, with reports routinelydirectedto the infectionconcan providecrucialinsights into the evaluationand analytrol program.
sis of problemsencounteredin outcomes management.55
The epidemiologicalstrategies that are used successfully
ReferenceLaboratory Testing
Referenceimmunologyand microbiologylaboratory in infection control programs are the same as those
testing, includingappropriatemoleculartyping of organ- stressed in statistical-process control and qualityisms, shouldbe availableon requestandin a timelyfashion improvementtheories.56'57
The infectioncontrolprogramalwayshas been a critfromregionalpublichealth,commercial,or university-based
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Vol.19 No. 2
PAPER
SHEA POSITION
icalpartof the hospital'sstrategyto conserve resourcesby
prevention and control of adverse infections outcomes.
Prevention and control of nosocomial infections has
allowed institutionsto decrease length of stay, decrease
morbidity,decrease costs, maximize appropriateuse of
In addition,
materials,andincreasepatientsatisfaction.4,12,13
preventionof adverse infections outcomes in healthcare
workers has resulted in decreased days off work,
decreased personnelcosts, and increasedemployee satisfactionwith betterworkermorale.18-20,38,39
Rose notes thatICPscan be instrumentalin defining
a set of indicatorsfor adverseoutcomes,developingmethods of case-finding,and subjectingthese indicatorsto careA scope of practicethatencompassful scientificscrutiny.54
es many areas of qualityimprovement,includinginfection
control,maybe an areaof interestfor manyICPs.
One of the limitations of the hospital-focused
approachhas been thatinfectioncontrolpreventionefforts,
those interventioneffortsthatconstitutethe "effectorarm"
of the infection control program, are restricted to the
patient'sexperiencein the hospital.By expandingepidemiologyprogramsthroughoutthe continuumof care,newprevention opportunitiesare opened for reducingthe risk of
nosocomialinfections,by reducingboth the patient'ssusceptibilityandthe risk of exposure.This maybe particularly importantto preventthe furtherspreadof antimicrobialresistant microorganismsbetween nursing homes and
acute-carehospitals,as well as within the community.In
addition, this expansion beyond the hospital will help
improve in-hospitalcare through improved data upon
which to base assessments, as with postdischargesurveillance of surgical-siteinfections.
Infectioncontroland quality-improvement
programs
conduct their activitiesaccordingto a similar paradigm:
ongoing data collection and analyses, problem identification and definition,interventionto improveoutcomes,and
reassessmentto ensurethatthe interventionhas led to the
desired result. The intense interest in measurement of
healthoutcomesin recentyears confirmsthe criticalrole of
datacollectionandanalysisin the qualityprocess.This critical activityalso is the most problematicbecause of the
inherent difficultyin acquiringand maintainingdata in a
complex healthcaresetting and because the markedvariabilityof populationsand systems confoundscomparison
betweeninstitutions.These aspects of qualitymanagement
have been studiedand refinedin the field of infectioncontrol for over 30 years and have led to some remarkably
sophisticatedanalyses.
The recommendationsof this document establish
the current essential elements of infection control programs as a foundationfor bridgingthe science of healthcare epidemiologyfrom hospitalinfectioncontrolto infection control in other sites of healthcare delivery and to
other aspects of patientcare and healthcaresupport services beyondinfectioncontrol.The successorsto this panel
will develop a follow-uparticle that will describe infection
control programsin various out-of-hospitalsettings, such
as long-termcare, home care, and ambulatorycare.These
121
are the most rapidlyexpandingareas of healthcareindustry in the UnitedStates,and there is a clearneed for infection controlprogramsthat are adaptedto the differences
between those settings and the hospital.It also would be
usefulfor anotherpanelto outlinethe transitionfromusing
epidemiologyprimarilyfor infectioncontrolpracticeto an
expandeduse of epidemiologicalprinciplesand methods
for the preventionand controlof other adverse events, as
well as to a more general understandingof qualityassessment and outcomesmeasurement.
The Consensus Panel Recommendationsare as
follows:
REQUIREMENTS FOR INFRASTRUCTURE
AND ESSENTIAL ACTIVITIES OF
INFECTION CONTROL AND
EPIDEMIOLOGY IN HOSPITALS
Where possible, the panel used an evidence-based
approach.Recommendationsthereforeare categorizedin
the Table,using a modificationof the scheme developedby
the ClinicalAffairsCommitteeof the InfectiousDiseases
Society of America and the CDC HICPACclassification
scheme58,59:
FUNCTIONS
Managing Critical Data and Information
Recommendation 1: Surveillanceof nosocomial
infectionsmust be performed.CategoryI
The surveillanceprocess should incorporateat least
the followingelements:
. Identificationand descriptionof the problemor
event to be studied;
. Definitionof the populationat risk;
. Selection of the appropriate methods of
measurement,includingstatisticaltools and risk
stratifications;
. Identificationand descriptionof datasources and
datacollectionpersonneland methods;
. Definitionof numeratorsand denominators;
. Preparationand distributionof reportsto
appropriategroups;and
. Selectionof specificevents to be monitoredshould
be guided by validated, nationally available
benchmarksappropriately
adjustedfor patient
risks, so that meaningfulcomparisonscan be
made.
Recommendation 2: Surveillance data must be
analyzedappropriatelyand used to monitorand improve
infectioncontroland healthcareoutcomes.CategoryI
Recommendation 3: Clinical performance and
assessment indicatorsused to supportexternal comparative measurementsshould meet the criteriadelineatedby
SHEAandAPIC.28CategoryII
Specifically,these indicatorsand their analysesmust
addressthe followingparameters:
. Relationto outcomeor process;
. Abilityto measurevariationin quality;
. Definitionof numeratorsand denominators;
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122
INFECTIONCONTROLAND HOSPITALEPIDEMIOLOGY
February 1998
TABLE
RECOMMENDATION
CATEGORIES
I.Strongly
recommended
II.Recommended
III.Recommended
whenrequired
by
rulesorregulations
government
recommended
forimplementation
basedon:
Strongly
. Evidence
fromatleastoneproperly
controlled
trial,or
randomized,
. Evidence
fromatleastonewell-designed
clinical
trialwithout
randomization,
or
. Evidence
fromcohortorcase-control
studies
analytical
frommorethanonecenter),or
(preferably
. Evidence
frommultiple
time-series
studies.
forimplementation
Recommended
basedon:
. Published
clinical
ordescriptive
studies,
experience
or
. Reports
ofexpertcommittees,
or
. Opinions
ofrespected
authorities.
andfeasibility
of data
. Reliability,
completeness,
collection;
. Appropriate
riskadjustment;
. Comparability
ofpopulations;
andcaseseverity
mixadjustments
forexternal
comparison;
. Training
forindicator
implementation;
required
and,
. Applicable
benchmarks
ofstandards
ofcare
EmployeeHealth
Recommendation
9:Theinfection
control
program
shouldworkcollaboratively
withthe facility's
personnel
healthprogram
II
personnel.
employee
Category
. Theinfection
shouldreviewand
controlprogram
developedin the
approveall policiesand procedures
healthprogram
thatrelatetothetransmission
of
employee
inthehospital.
infections
to
. Infection
control
shouldbe available
personnel
forconsultation
healthprogram
the employee
regarding
Setting and RecommendingPolicies and Procedures
diseaseconcerns.
infection
Recommendation
4: Written
prevention infectious
10: Atthetimeofemployment,
mustbe established,
Recommendation
andcontrolpoliciesandprocedures
be evaluated
should
Both
all
and
maintained, updated
facility
personnel
bytheemployee
periodically.
implemented,
to communicable
healthprogram
forconditions
relating
CategoriesII and III
should
andprocedures
bescientifically diseases. Both CategoriesII and III
. Thepolicies
shouldinclude
thefollowing:
Theevaluation
valid.
immunization
status
. Medicalhistory,including
shouldbereviewed
. Thepoliciesandprocedures
andassessment
forconditions
thatmaypredispose
andcost.
forpracticality
ortransmitting
communicatoacquiring
shouldleadto
. Thepoliciesandprocedures
personnel
blediseases;
improvedpreventionor improvedpatient
. Tuberculosis
skintesting;
outcomes.
. Serologicscreeningfor vaccine-preventable
Recommendation5: Policiesand procedures
ifindicated;
Both
forperformance.
shouldbe monitored
diseases,
periodically
examinations
asareindicated
. Suchmedical
bythe
CategoriesII and III
above.
or
11: Appropriate
Recommendation
employees
Compliance WithRegulations, Guidelines, and
workersshouldhaveperiodicmedical
otherhealthcare
Accreditation Requirements
relatedto infecto assessfornewconditions
facilitiesshould evaluations
6: Healthcare
Recommendation
onpatient
to assistin maintaining tiousdiseasesthatmayhaveanimpact
use infection
controlpersonnel
care,the
and accreditation employee,or otherhealthcare
withrelevantregulatory
workers,whichshould
compliance
skin-test
andtuberculosis
includereviewof immunization
II
requirements.
Category
controlpersonnel status,if appropriate.Both CategoriesII and III
7: Infection
Recommendation
medical
confidential
. Allfacilities
shouldmaintain
orotherrelevant
accesstomedical
shouldhaveappropriate
workers.
onallhealthcare
information records
whocanprovide
records
andto staffmembers
shouldhavethe
healthprogram
. The employee
withregard
oftheinstitution's
ontheadequacy
compliance
andtuberculoimmunization
to trackemployee
II
andguidelines.
toregulations,
standards,
capability
Category
status.
control
8: Theinfection
Recommendation
program sisskin-test
mustbeoffered
12: Employees
Recommendation
liaisonto,appropriate
shouldcollaborate
with,andprovide
diseases.
for communicable
immunizations
ofcommu- appropriate
forreporting
localandstatehealthdepartments
andto assistwith BothCategoriesI and III
nicablediseasesandrelatedconditions
shouldbe basedon regulatory
. Immunizations
IIandIII
BothCategories
diseases.
ofinfectious
control
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Vol.19 No. 2
PAPER
SHEA POSITION
requirementsand Advisory Committeeon Immunization
Practicesrecommendationsfor healthcareworkers.
Recommendation 13: The employee health programshoulddeveloppoliciesandproceduresfor the evaluation of ill employees, including assessment of disease
communicability,indications for work restrictions, and
management of employees who have been exposed to
infectious diseases, including postexposure prophylaxis
andworkrestrictions.CategoryI
Intervening Directly to Prevent Transmission of
Infectious Diseases
Recommendation 14: Allhealthcarefacilitiesmust
havethe capacityto identifythe occurrenceof outbreaksor
clustersof infectiousdiseases. CategoryI
. Infectioncontrolpersonnelshouldreviewmicrobiology records regularlyto identifyunusual clusters or a
incidenceof certainspecies or strainsof
greater-than-usual
microorganisms.
. In patientareas of the healthcarefacilityin which
activeprospectivesurveillanceis not conducted,infection
controlprogramsshouldmaintainregularcontactwithclinical, medical, and nursing staff in order to ascertain the
occurrence of disease clusters or outbreaks,to assist in
maintenanceand monitoringof infection control procedures,and to provideconsultationas required.
Recommendation 15: Allhealthcarefacilitiesmust
have access to the services of personneltrainedand experiencedin conductingoutbreakinvestigations.CategoryII
Recommendation 16: When an outbreakoccurs,
the infectioncontrolteam must have adequateresources
and authorityto ensure a comprehensiveand timelyinvestigationandthe implementationof appropriatecontrolmeasures. CategoryII
Education and Training of Healthcare Workers
Recommendation 17: Healthcarefacilities must
provideongoing educationalprogramsin infectionprevention and controlto healthcareworkers.Both CategoriesII
andIII
. Infectioncontrol personnel with a knowledge of
epidemiologyand infectiousdiseases should be activeparticipantsin the planningand implementationof the educationalprograms.
Recommendation 18: Educational programs
should be evaluated periodicallyfor effectiveness, and
attendanceshouldbe monitored.Both CategoriesII and III
. Educationalprogramsshouldmeet the needs of the
groupor departmentforwhichthey aregivenandmustprovide learningexperiencesfor people with a wide range of
educationalbackgroundsandworkresponsibilities.
RESOURCES
Personnel
Recommendation 19: The personneland supporting resources,includingsecretarialservices,availableto the
hospitalepidemiologyandinfectioncontrolprogramshould
be proportional
to the size, complexity,andestimatedriskof
123
the populationserved by the institution.Category
II
Recommendation 20: All hospitals should have
the continuingservices of a trained hospital epidemiologist(s) and ICP(s). CategoryI
Recommendation 21: ICPs shouldbe encouraged
to obtainCertificationin InfectionControl.CategoryII
Nonpersonnel
Recommendation 22: Healthcarefacilitiesshould
provide or make available,in a timely fashion, sufficient
office space and equipment,statisticaland computersupport,andclinicalmicrobiologyandpathologylaboratoryservices to supportthe nosocomialinfectionsurveillance,preII
vention,andcontrolprogramof the institution.Category
Recommendation 23: Resources should be provided for continuingprofessionaleducationof hospitalepidemiologistsand ICPs.CategoryII
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