* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Requirements for Infrastructure and Essential Activities of Infection
Survey
Document related concepts
Clostridium difficile infection wikipedia , lookup
Neglected tropical diseases wikipedia , lookup
Sarcocystis wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Anaerobic infection wikipedia , lookup
Trichinosis wikipedia , lookup
Sexually transmitted infection wikipedia , lookup
Marburg virus disease wikipedia , lookup
Hepatitis C wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Dirofilaria immitis wikipedia , lookup
Schistosomiasis wikipedia , lookup
Hepatitis B wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Oesophagostomum wikipedia , lookup
Transcript
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 Stable URL: http://www.jstor.org/stable/30142002 . Accessed: 13/06/2014 14:08 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. . The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaborating with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology. http://www.jstor.org This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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. This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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. This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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; This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 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 REFERENCES 1. AmericanHospitalAssociation:Preventionandcontrolof Staphylococcus infectionsin hospitals,in US Public Health Service-Communicable Disease Centerand NationalAcademyof Sciences-National Research Council.Proceedingsof the National Conferenceon Hospital-Acquired Disease. Atlanta,GA: CommunicableDisease Center; Staphylococcal 1958:XXIIDOCVI. 2. GarnerJS, Bennett JV, Scheckler WE, Maki DG, BrachmanPS. Surveillanceof nosocomialinfections,in Centersfor Disease Control. Proceedingsof the InternationalConferenceon NosocomialInfections. Atlanta,GA:Centersfor Disease Control;1970:277-281. 3. JointCommissionon Accreditationof Hospitals.Accreditation Manual for Hospitals.Chicago, IL: Joint Commission on Accreditationof Hospitals;1976. 4. HaleyRW,CulverDH,WhiteJ, MorganWE,AmberTG,MannVP,et al. The efficacyof infectionsurveillanceand controlprogramsin preventing nosocomialinfectionsin US hospitals.AmJ Epidemiol1985;121:182205. 5. HaleyRW,TenneyJH, LindseyII JO, GarnerJS, BennetJV.How frequentare outbreaksof nosocomialinfectionin hospitals?InfectControl 1985;6:233-236. 6. HaleyRW,MorganWE,CulverDH,WhiteJ, AmberTG,MosserJ, et al. Update from the SENIC project. Hospitalinfection control:recent progress and opportunitiesunder prospectivepayment.Am J Infect Control1985;13:97-108. 7. Wenzel RP The economics of nosocomialinfections.J Hosp Infect 1995;31:79-87. 8. Crede W, HierholzerWJ. Linkinghospitalepidemiologyand quality assurance: seasoned concepts in a new role. Infect ControlHosp Epidemiol1988;9:42-44. 9. JointCommissionon Accreditationof HealthCareOrganizations. 1997 Accreditation Manualfor Hospitals.OakbrookTerrace, Comprehensive IL:Joint Commissionon Accreditationof HealthCare Organizations; 1997. 10. FarrBM.Organization of infectioncontrolprograms.In:AbrutynE, ed. SaundersInfectionControlReferenceService.Philadelphia,PA: WB SaundersCo;1997:13-15. 11. Epidemiologyandpreventionof nosocomialinfectionsof organsystems. Section III. In: MayhallCG, ed. HospitalEpidemiologyand Infection Control.Baltimore,MD:Williams& Wilkins;1996:139-269. 12. Perspectives.Section 1. In: WenzelRP,ed: Preventionand Controlof NosocomialInfections,3rd ed. Baltimore,MD: Williams& Wilkens; 1997:1-54. 13. MillerPJ,FarrBM, GwaltneyJMJr.Economicbenefitsof an effective infectioncontrolprogram:case studyandproposal.ReviewsofInfectious Diseases1989;11:284-288. 14. NystromB. Impactof handwashingon mortalityin intensivecare:examinationof the evidence.InfectControlHospEpidemiol1994;15:435-436. 15. PeterJE, CruseMB, FoordR.The epidemiologyof woundinfection:a 10-year prospective study of 62,939 wounds. Surg Clin N Am 1980;60(1):2740. 16. CondonRE, SchulteWJ, MalangoniMA, Anderson-Teschendorf MJ. Effectivenessof a surgical wound surveillanceprogram.Arch Surg 1983;118:303-307. This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions 124 INFECTIONCONTROLAND HOSPITALEPIDEMIOLOGY 17. ClassenDC, EvansRS,PestotnikSL,HornSD, MenloveRL,BurkeJP. of antibioticsand the risk of The timingof prophylacticadministration infection.N EngJ Med1992;326:281-286. surgical-wound 18. DiekemaDJ, DoebbelingBN. Employeehealth and infectioncontrol. InfectControlHospEpidemiol1995;16:292-301. 19. PolderJA, TablanOC, WilliamsWW.Personnelhealth services. In: BennettJV,BrachmanPS, eds:HospitalInfections,3rded. Boston,Mk Little,BrownandCo;1992:31-61. 20. FalkP.Infectioncontroland employeehealthservice. In:MayhallCG, ed. Hospital Epidemiologyand Infection Control.Baltimore, MA: Williams& Wilkins;1996:1094-1099. 21. AnglimAM, CollmerJE, LovingTJ, BeltranKA,CoynerBJ,AdalK, et al.An outbreakof needlestickinjuriesin hospitalemployeesdue to needles piercinginfectiouswaste containers.InfectControlHospEpidemiol 1995;16:570-576. 22. FaoagaliJL,DaveyD. Chickenpoxoutbreakamongthe staffof a large urbanadulthospital:costs of monitoringandcontrol.AmJ InfectControl 1995;23:247-250. 23. HaleyRW,WhiteJW,CulverDH,HughesJM.The financialincentivefor hospitalsto preventnosocomialinfectionsunderthe prospectivepayfroma nationallyrepresentament system.An empiricaldetermination tive sample.JAMA1987;257 (12):1611-1614. 24. EhrenkranzNJ.The efficacyof a Floridahospitalconsortiumfor infectioncontrol,1975-1982.InfectControl1986;7:321-326. 25. ShewhartWA.Statisticalmethodfromthe viewpointof qualitycontrol. Washington,DC: GraduateSchool of the Departmentof Agriculture; 1939.ReprintedNew York,NY;Dover; 26. GaribaldiRA,BurkeJ. Surveillanceand controlof antibioticuse in the hospital.AmJ InfectControl1991;19:164-170. 27. NationalNosocomialInfectionSurveillanceSystems.Nosocomialinfeclimitationsandpossiblesolutions. tionrateforinterhospitalcomparison: InfectControlHospEpidemiol1991;12:609-621. 28. The QualityIndicatorStudyGroup.An approachto the evaluationof qualityindicatorsof outcome of care in hospitalizedpatients,with a focus on nosocomialinfectionindicators.InfectControlHospEpidemiol 1995;16:308-316. 29. Keita-Perse0, GaynesRP.Severityof illness scoringsystemsto adjust nosocomialinfection rates: a review and commentary.Am J Infect Control1996;24:429-434. infectionrates:the 30. GaynesRP,SolomonS. Improvinghospital-acquired CDCexperience.Journalon QualityImprovement 1996;22:457467. 31. Brennan PJ, AbrutynE. Developingpolicies and guidelines. Infect ControlHospEpidemiol1995;16:512-517. 32. Abrutyn E, GoldmannDA, Scheckler WE, eds. SaundersInfection ControlReferenceService.Philadelphia, WB SaundersCo; 33. KaunitzKRK,KaunitzAM. Legal aspects of hospital infections.In: 3rded. Boston:Little, BennettJV,BrachmanPS,eds. HospitalInfections. Brown& Co;1992:533-573. 34. BobinskiMA.Legalissues in hospitalepidemiologyand infectionconand InfectionControl. trol. In: MayhallCG, ed. HospitalEpidemiology Baltimore,MD:Williams& Wilkins;1996:11384145. 35. McDiarmidM, GamponiaMJ,RyanMAK,HirshonJM,GillenNA, M. Tuberculosisin the workplace:OSHA'scomplianceexperience. InfectControlHospEpidemiol1996;17:159-164. 36. Valenti Al, Decker MD. OSHA inspections. Infect Control Hosp Epidemiol1995;16:478-482. 37. NettlemanMD. Preparingfor and survivinga JCAHOinspection.Infect ControlHospEpidemiol1995;16:236-239. 38. Centersfor Disease Controland Prevention.Draftguidelinefor infec- February 1998 tioncontrolin healthcarepersonnel,1997,Centersfor Disease Control. FederalRegisterSeptember8, 1997;62:47275-47327. 39. NicholKL,LindA, MargolisKL,MurdochM, McFaddenR, HaugeM, et al. Effectivenessof vaccinationagainstinfluenzain healthyworking adults.N EnglJ Med1995;333:889-893. 40. McGowanJEJr,MetchockBG.Basicmicrobiologicsupportforhospital InfectControlHospEpidemiol1996;17:298-303. epidemiology. 41. Beck-SagueC, JarvisWR,MartoneWJ.Outbreakinvestigations.Infect ControlHospEpidemiol1997;18:138-145. 42. Barg NL. An introductionto molecularhospital epidemiology.Infect ControlHospEpidemiol1993;14:395-396. 43.JarvisWR Usefulnessof molecularepidemiologyfor outbreakinvestigations.InfectControlHospEpidemiol1994:15:500-503. 44. EhrenkranzNJ,RichterEI,PhillipsPM,ShultzJM.An apparentexcess of operativesite infections:analysisto evaluatefalse-positivediagnosis. InfectControlHospEpidemiol1995;16:712-716. 45. HoffmannKK,ClontzEP Educationof healthcare workersin the prevention of nosocomial infections. In: Mayhall CG, ed. Hospital andInfectionControl.Baltimore,MD:Williams& Wilkins; Epidemiology 1996:1086-1094. 46. HaleyRW.The developmentof infectionsurveillanceand controlprograms. In: BennettJV,BachmanPS, eds. HospitalInfections.3rd ed. Boston,MA:Little,Brown& Co;1992:63-77. 47. Centersfor Disease Control.Publichealthfocus:surveillance,preventionandcontrolof nosocomialinfections.MMWR1992;41:783-787. 48. Wong ES. Surgical site infections. In: Mayhall CG, ed. Hospital andInfectionControl.Baltimore,MD:Williams&Wilkins; Epidemiology 1996;154-175. 49. CertificationBoard of InfectionControl.CBICCandidateHandbook. Boardof InfectionControl;1996:1-28. Lenexa,KS:Certification 50. Instituteof Medicine.Dick RS, Steen EB, eds. The Computer-Based An EssentialTechnology PatientRecord: for Healthcare.Washington,DC: NationalAcademyPress; 51.TenoverFC,ArbeitRD,GoeringRV.Howto select andinterpretmolecularstraintypingmethodsforepidemiologicalstudiesof bacterialinfections: a review for healthcare epidemiologists.Infect ControlHosp Epidemiol1997;18:426-439. S. Designingsurveillance 52. MassanariRM,WilkersonK, Swatzendruber for infectious outcomes of medical care. Infect Controland Hosp Epidemiol1995;16:419-426. 53. Wenzel,R, Carlson,B. Hospitalepidemiology:beyondinfectioncontrol News1988;10:7-9. andtowardqualityassurance.ClinicalMicrobiology the righttime,the 54. RoseRCIII.Infectioncontrolto qualityimprovement: right place, the work to be done. ClinicalPerformanceand Quality HealthCare1997;5:16-19. a criticaltool for infectionprofes55. RutalaWA,WeberDJ.Epidemiology: sionals.AmJ InfectControl1997;25:193-194. 56. BrewerJH,GasserCS.The affinitybetweencontinuousqualityimprovement and epidemic surveillance. Infect Control Hosp Epidemiol 1993;14:95-98. 57. SellickJAJr.The use of statisticalprocesscontrolchartsin hospitalepidemiology.InfectControlHospEpidemiol1993;14:649-656. 58. GrossPA,BarrettTL,DellingerEP,KrausePJ,MartoneWJ,McGowan JE, et al. InfectiousDiseases Societyof Americaqualitystandardsfor infectiousdiseases.Purposeof qualitystandardsforinfectiousdiseases. ClinInfectDis 1994;18:421. 59. Pearson ML, the Hospital Infection Control Practices Advisory Committee.Guidelinefor preventionof intravascular-device-related infections.InfectControlHospEpidemiol1996;17:438-473. This content downloaded from 108.56.73.194 on Fri, 13 Jun 2014 14:08:03 PM All use subject to JSTOR Terms and Conditions