The Issue in Focus

According to estimates, about 1 in 25 hospital patients has at least one HAI on any given day. In 2011, an estimated 722,000 HAIs occurred among 648,000 patients in U.S. acute care hospitals. (Magill et al.) As shown in Figure. Distribution of Healthcare-Associated Infections (HAIs) in U.S. Hospitals, 2011, pneumonia and surgical site infection are the most common types of infection.

Patient Safety

Epidemiology

In the aforementioned study, an estimated 75,000 of the 648,000 hospital patients who had HAIs in 2011, or roughly 12%, died during their hospitalization (Magill et al.). Although the study did not determine whether the HAIs were the cause of death, the statistic is concerning. For comparison, roughly the same number of people died due to diabetes in 2013, which was the seventh most frequent cause of death in that year (CDC "Leading Causes").

Mortality is not the only concern. HAIs are associated with significant morbidity in and of themselves, and they may complicate care of the patient's other conditions. They increase morbidity, costs, and length of stay even after underlying illness is adjusted for (Sydnor and Perl).

HAIs have garnered attention from the federal government. The U.S. Department of Health and Human Services' National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination provides a road map for preventing HAIs in acute care hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities. Phase one, focused on acute care hospitals, outlines eight metrics with corresponding five-year goals for reducing specific HAIs. (U.S. HHS)

MDROs and Antimicrobial Use

In April 2014, the World Health Organization (WHO) issued a report that found that in many parts of the world, drug resistance has reached "alarming" levels and that a "major gap in knowledge" exists regarding the current threat level of antibiotic resistance in common bacteria. The report stated, "A post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century." (WHO)

The following year, the White House announced a five-year plan to combat antibiotic resistance. Developed in response to an executive order, National Action Plan for Combating Antibiotic-Resistant Bacteria lists strengthening antibiotic stewardship programs in inpatient, outpatient, and long-term care settings as a subobjective. (White House)

Coordination with other healthcare organizations is also important. The Centers for Disease Control and Prevention (CDC) has called on healthcare organizations to work more closely together to stop the spread of antibiotic-resistant organisms. A 2015 report from the agency concluded that coordinated approaches to halt the spread of resistant organisms—for example, by implementing systems to alert receiving facilities when enhanced infection control is needed for transferred patients who are colonized or infected with resistant organisms—would have more impact than only programs based in individual facilities. Such approaches could avert an estimated 619,000 antibiotic-resistant HAIs over five years, the agency estimates. (Slayton et al.)

Financial and Operational Burden

Infections are also costly and operationally burdensome. Estimates of the direct medical costs of HAIs to U.S. hospitals range from $28 billion to $45 billion (2007 dollars) annually (Scott). The Pennsylvania Health Care Cost Containment Council found that in Pennsylvania in 2010, the average Medicare fee-for-service payment for hospital stays of patients with HAIs was $21,378. By contrast, the average payment for patients without HAIs was $6,709. The average length of stay was 22 days among patients with an HAI, compared with only 5 days among patients without an HAI. Among patients with an HAI, 42% were readmitted within 30 days, compared with only 16% of patients without an HAI. (Pennsylvania Health Care Cost Containment Council)

These statistics are striking even in light of the increased susceptibility of sicker patients—who are likely to require more expensive care and longer stays and are more likely to be readmitted—to infections. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) offer tools for calculating the costs of HAIs and making a business case for infection prevention and control programs (see Resource List).

The cost of treating HAIs is not offset largely by reimbursement, as some mistakenly believe. HAIs do not garner higher reimbursement based on diagnosis-related group (there are no codes for HAIs), HAIs divert beds and other resources that could be used for patients with reimbursable conditions, and rates of certain HAIs and readmissions may affect payment under federal programs to reduce healthcare-associated conditions and readmissions (see the discussion Regulations and Standards). In addition, patients who contract HAIs may sue, and noncompliance with applicable regulations could lead to monetary penalties. ("Demonstrating")

Hospitals may face other, less direct costs as well. Outbreaks in particular often impose significant burden because of the difficulty managing infected patients, personnel use of sick leave and overtime, use of additional supplies, cleaning expenses, and lost revenue due to temporary closures. Infection control issues that become public could damage the hospital's reputation and affect market share.

Litigation

Tort liability is another major concern. Patients and families affected by a large outbreak of Clostridium difficile at a Canadian hospital reached a settlement of $9 million CAD with the hospital. The class action lawsuit alleged that the facility was not properly maintained, cleaned, or disinfected. The outbreak occurred between May 2006 and December 2007, caused 91 deaths, and affected a total of 225 patients. The extent of the outbreak was not disclosed until 2008. Reports state that this was the worst outbreak of C. difficile in Ontario, Canada, and had caused the deaths of patients undergoing routine surgeries. ("Court Approves"; Walters; "Jo Brant Hospital")

regulations and standards

Several laws and regulations, Occupational Safety and Health Administration (OSHA) standards, and guidelines developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC)—a federal advisory committee to CDC—bear on infection control. This discussion reviews laws, regulations, standards, and guidelines of particular concern, but it is not exhaustive.

CMS Regulations

Conditions of Participation

The Centers for Medicare and Medicaid Services' (CMS) Condition of Participation addressing infection control requires the following (42 CFR § 482.42):

The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

(a) Standard: Organization and policies. A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.

(1) The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

(2) The infection control officer or officers must maintain a log of incidents related to infections and communicable diseases.

(b) Standard: Responsibilities of chief executive officer, medical staff, and director of nursing services. The chief executive officer, the medical staff, and the director of nursing services must—

(1) Ensure that the hospital-wide quality assurance program and training programs address problems identified by the infection control officer or officers; and

(2) Be responsible for the implementation of successful corrective action plans in affected problem areas.

Hospitals should consider reviewing CMS's guidance to surveyors to learn how surveyors will evaluate compliance with regulations. They may also consider periodically using the CMS surveyor worksheet addressing infection prevention and control (see Resource List) as an audit tool.

Payment Initiatives

The following infections are among the conditions included in CMS's hospital-acquired conditions program:

• Catheter-associated urinary tract infection
• Vascular-catheter-associated infection
• Surgical site infection following:
• Coronary artery bypass graft surgery (mediastinitis)
• Bariatric surgery (laparoscopic gastric bypass, gastroenterostomy, or laparoscopic gastric restrictive surgery)
• Orthopedic procedures of the spine, neck, shoulder, or elbow
• Cardiac implantable electronic device surgery

When grouped based on scores representing the full list of hospital-acquired conditions, hospitals in the highest quartile are subject to a 1% payment reduction. (CMS "Hospital-Acquired Conditions")

In addition, the Hospital Value-Based Purchasing Program, which adjusts payment based on performance on a defined set of measures, includes process measures related to HAIs and an outcome measure related to central-line-associated bloodstream infections (CMS "Hospital Value-Based Purchasing").

Other Laws and Regulations

Federal. Other relevant federal regulations and enforceable standards include the following:

• The Occupational Safety and Health Act, especially the general-duty clause. For more information, see the guidance article The OSH Act: Best Practices for Compliance.
• The Health Insurance Portability and Accountability Act. See the guidance articles Health Information Privacy Standards and Health Information Security Standards.
• OSHA standards:
• Bloodborne pathogens (29 CFR § 1910.1030). From October 2013 through September 2014, the bloodborne pathogens standard was by far the OSHA standard most often cited in hospitals (OSHA). See the guidance article OSHA's Bloodborne Pathogens Standard.
• Recording and reporting occupational injuries and illnesses (29 CFR § 1904). See the guidance article OSHA Illness and Injury Record-Keeping Standard.
• Respiratory protection (29 CFR § 1910.134). See the guidance article Developing a Tuberculosis Infection Control Program.
• Federal authority to impose isolation and quarantine.
• U.S. Department of Transportation regulations concerning transport of regulated medical waste.

State and local. State and local regulations or codes that may have implications for infection prevention and control include the following:

• Building codes
• Confidentiality and privacy laws
• Extra protections for certain health information (e.g., HIV testing, diagnosis, and treatment)
• Laws addressing isolation and quarantine
• Laws requiring reporting of certain infectious diseases
• Laws requiring public reporting of HAI rates
• Laws addressing disposal of regulated medical waste

Standards and Guidelines

Following are other standards and guidelines with general infection control guidance or implications (see Resource List for links to many of them):

• APIC text on infection control
• HICPAC guideline on precautions and isolation
• CDC and WHO hand hygiene guidelines and information (See the guidance article Hand Hygiene in the Healthcare Setting.)
• HICPAC guideline on MDROs
• Infectious Diseases Society of America (IDSA)/SHEA guidelines on developing an antimicrobial stewardship program and SHEA/IDSA/Pediatric Infectious Diseases Society (PIDS) policy statement on antimicrobial stewardship
• The Facility Guidelines Institute's (FGI) hospital design and construction guidelines
• HICPAC guidelines on environmental infection control
• SHEA recommendations regarding animals in healthcare facilities
• HICPAC guideline on disinfection and sterilization
• HICPAC guideline on preventing infection in healthcare personnel
• Advisory Committee on Immunization Practices recommendations for immunization of healthcare personnel (See the guidance article Immunization of Healthcare Personnel.)
• U.S. Public Health Service guidelines for management of potential exposure to bloodborne pathogens (See the guidance article Occupational Exposure to Blood or Body Fluids.)
• Accreditation standards

Although disease-specific guidelines are outside the scope of this guidance article, CDC, SHEA, APIC, IDSA, and other organizations have published guidelines or information addressing specific infectious diseases—including methicillin-resistant Staphylococcus aureus, pneumonia, C. difficile, tuberculosis, norovirus, and respiratory tract infections. For more information on several of these, see the guidance article High-Profile Healthcare-Associated Infections.

action plan

Support the Infection Prevention and Control Program

Action Recommendation: Ensure that the infection prevention and control program has an adequate structure, administrative support, and resources to be effective.

The main functions of an infection prevention and control program are to

• manage critical data and information (including surveillance data),
  
• develop and recommend policies and procedures,
• directly intervene to prevent disease transmission, and
• educate and train personnel, patients, and caregivers (Scheckler et al.).

The structure of an infection prevention and control program should be tailored to the organization's characteristics and needs. For an example of how one health system has structured its infection prevention and control program, seeInfection Prevention and Control Program: Structure and Duties.

One important consideration is whether the program has adequate infrastructure, resources, and administrative and other support. An effective program may be well worth the investment. In a study of the costs of HAIs at 28 community hospitals in the southeastern United States, the median cost of HAIs per hospital ($595,000) was 4.6 times the median amount budgeted for infection prevention ($129,000). Describing the economic cost of HAIs as "enormous," the authors reported that HAIs cost the network more than $26 million annually. (Anderson et al.) APIC and SHEA offer tools for calculating the costs of HAIs and making a business case for infection prevention and control programs (see Resource List).

Risk assessment and program evaluation. Without a structured approach, it may be difficult to identify and prioritize infection risks. An effective tool for identifying infection risks is the infection prevention and control program risk assessment (which is distinct from the infection control risk assessment used for construction projects). In such an assessment, the organization identifies

• the likelihood of specific risks (e.g., lack of hand hygiene, MDRO infections, failure to use universal precautions);
• the potential health, financial, legal, and regulatory effects of each risk; and
• the effectiveness of current systems in preventing each risk (APIC Sierra).

Based on the findings, the organization can prioritize the risks and set objectives.

The organization should also evaluate the effectiveness of the infection prevention and control program at least annually and whenever there are significant changes (e.g., in infection risks).

Support Individuals and Groups with Infection Control Responsibility

Action Recommendation: Ensure that individuals and groups with infection prevention and control responsibilities have adequate ongoing opportunities for education and networking, work time dedicated to infection control, resources, and administrative support.

Many individuals and groups throughout a hospital share responsibility for infection prevention and control. Individuals with direct responsibility are as follows.

The infection preventionist. This individual often has a background in nursing, microbiology, public health, or medical technology. He or she typically collaborates with other groups throughout the organization, provides education and training, serves as a consultant, implements surveillance and infection prevention and control initiatives, and engages in patient safety and quality improvement. (APIC)

The infection preventionist should have necessary competency. APIC offers professional standards and a conceptual model for competency in infection prevention and control. Equally important is ongoing professional development. Hospitals should consider paying for infection preventionists' membership in a professional society for infection prevention and control, as well as allotting time for them to attend society meetings and events and pursue further education and certification in infection control. Resource List links to relevant organizations and resources.

The number of full-time infection preventionists needed in hospitals may depend on a variety of factors, such as scope of the infection prevention program, characteristics of the patient population, and facility needs. But general estimates range from one infection preventionist for every 100 beds to one for every 178 beds. (APIC)

The healthcare epidemiologist. This individual is often an infectious-diseases physician. He or she may serve as the chair of, a technical advisor to, or a member of the infection prevention committee.

Groups with direct responsibility for infection prevention are as follows.

The infection prevention team. The infection prevention team comprises the core people responsible for carrying out the components of the infection prevention program. It typically includes the infection preventionist, the chair of the infection prevention committee, and the healthcare epidemiologist. It may also include a representative from occupational health or the administration. One person on the team will have designated responsibility for the infection prevention program.

The infection prevention committee. The hospital may also have an infection prevention committee (in fact, it is required in some states). The committee typically makes decisions, develops policies related to infection prevention, advocates for infection prevention, garners leadership and political support, and educates personnel. Often, it ratifies the suggestions of the infection prevention team. According to APIC, the committee should be multidisciplinary and meet regularly (e.g., monthly, quarterly). (APIC)

Maintain a Clean Environment

Action Recommendation: Maintain a clean environment.

Hospitals should consider how architectural and interior design features can help prevent and control infections. FGI's Guidelines for Design and Construction of Hospitals and Outpatient Facilities addresses many issues related to infection prevention and control. For more information, see Resource List and the guidance article Infection Control during Construction.

Organizations may also wish to consult HICPAC's guidelines for environmental infection control in healthcare facilities. The guidelines address the following topics (Sehulster and Chinn):

• Construction, renovation, repair, and demolition
• Air-handling systems
• Infection prevention and ventilation requirements for protective-environment rooms, airborne-infection isolation (AII) rooms, and operating rooms
• Measures to address other potentially infectious aerosol hazards (e.g., laser plumes)
• Prevention and control of waterborne organisms
• Cleaning and disinfection of environmental surfaces
• Cleaning of blood or other potentially infectious materials (OPIM)
• Laundry, bedding, and other textiles
• Carpeting and cloth furnishings
• Special pathogens (e.g., MDROs)
• Environmental sampling (only when indicated)
• Regulated medical waste
• Pest control
• Animals
• Plants and flowers

HICPAC's guideline on precautions and isolation makes recommendations regarding issues such as patient care equipment, environmental cleaning and disinfection (generally and for patients on specific types of precautions), protective environments and AII rooms, patient transport, and textiles and laundry (Siegel et al. "2007 Guideline"). HICPAC's MDRO guideline includes specific recommendations for environmental management of patients who are infected or colonized with an MDRO (Siegel et al. "Management").

In addition, SHEA has issued guidance to help organizations create or assess policies regarding animals in healthcare facilities. SHEA makes specific recommendations for each of four categories of animals: animals used for animal-assisted activities, service animals, research animals, and personal pets. The guidance addresses the importance of drafting written policies and procedures, selection criteria for therapeutic animals, infection control practices (e.g. preventing contact with other patients, processes for cleaning up after animals, hand hygiene concerns), rules governing movement throughout the facility, and exclusion criteria outlining which animals should be denied admittance and what circumstances should prompt an approved animal's removal from the facility. (Murthy et al.)

Clean, Disinfect, and Sterilize

Action Recommendation: Clean, disinfect, and sterilize instruments and equipment in accordance with guidelines and manufacturer instructions for use.

Absent proper cleaning, disinfection, and sterilization, medical equipment and environmental surfaces may help spread infection. HICPAC's guideline on disinfection and sterilization provides recommendations regarding cleaning, disinfection, and sterilization of medical devices used in patient care and cleaning and disinfection of the healthcare environment. The guideline emphasizes the importance of adhering to manufacturer instructions for use for both the cleaning, disinfection, or sterilization agent and the item being processed.

Although the guideline is rather technical, reviewing specific chemical disinfectants and methods of sterilization in detail, risk managers should understand the basic differences between cleaning, disinfection, and sterilization.

Cleaning. According to the guideline, cleaning is "the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces." It is usually done manually or mechanically using water and a detergent or enzymatic cleaner. (Rutala et al.) Ineffective cleaning of a device before it undergoes high-level disinfection or sterilization is a common problem. In fact, ineffective cleaning is one factor that frequently contributes to inadequate reprocessing of endoscopes and surgical instruments, which has repeatedly been on ECRI Institute's annual list of top 10 health technology hazards. (ECRI Institute)

Disinfection. The guideline states that disinfection is "a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects." In healthcare, liquid chemicals or wet pasteurization is typically used to disinfect items and surfaces.

Sterilization. According to the guideline, sterilization is "a process that destroys or eliminates all forms of microbial life." In healthcare, physical or chemical methods are typically used to sterilize items. (Rutala et al.)

The guideline uses the Spaulding classification, as follows, as a general approach for deciding whether disinfection or sterilization is necessary.

• Critical. These items enter sterile tissue or the vascular system (e.g., surgical instruments, cardiac and urinary catheters). HICPAC recommends sterilization for most items in this category.
• Semicritical. These items come in contact with mucous membranes or nonintact skin (e.g., respiratory therapy and anesthesia equipment, some endoscopes). HICPAC recommends at least high-level disinfection for most items in this category.
• Noncritical. These items and surfaces come in contact with intact skin but not mucous membranes (e.g., blood pressure cuffs, computers, bedrails, floors). HICPAC recommends low-level disinfection for most items in this category.

However, the guideline notes that exceptions are necessary in some situations (e.g., processing of devices with many intricate channels, presence of certain pathogens, spills of blood or OPIM) (Rutala et al.). The guidance articles Reprocessing in Central Service and Use of Reprocessed Single-Use Medical Devices offer more information.

Support Staff Members' Health

Action Recommendation: Address infection prevention and control issues involving healthcare personnel.

HICPAC's guideline on infection control in healthcare personnel presents an overview of infection prevention and control issues involving healthcare personnel. The guideline applies to all people, paid or unpaid, who work in healthcare settings and could be exposed to infectious materials or contaminated medical supplies, equipment, environmental surfaces, or air. (Bolyard et al.)

Some of the topics addressed in the guideline's recommendations are discussed in the following section. Other topics include immunization of healthcare personnel and management of occupational exposure to bloodborne pathogens. For more information on these issues, see the guidance articles Immunization of Healthcare Personnel and Occupational Exposure to Blood or Body Fluids.

Infection Prevention in the Occupational Health Service

The guideline reviews the elements of an occupational health service that are important for infection prevention and control, such as the following (Bolyard et al.). See also the discussion Train Staff for the guideline's recommendations regarding staff education and training and the guidance article The Hospital Occupational Health Service for an overview of the department.

Elements related to coordinated planning and administration include the following:

• Coordinate policy making and planning for the occupational health service among the department itself, hospital administration, infection prevention and control, clinical services, the pharmacy, other departments, and external agencies. Develop protocols to facilitate coordination.
• Write a policy for notifying infection prevention staff of personnel infections that require work restrictions or exclusion from work, clearance for return to work, work-related infections and exposures, and results of epidemiologic investigations.

Elements related to health inventories and assessments include the following:

• Perform health inventories—including immunization status and history of conditions that increase the person's chance of contracting or transmitting infectious diseases—before personnel begin duty or a new work assignment.
• Based on the results of the health inventory, perform directed physical and laboratory examinations (e.g., to detect conditions that increase the person's chance of acquiring or transmitting infectious diseases, to show whether future problems are work-related).
• Conduct other personnel health assessments as needed, such as to evaluate work-related illnesses or exposures.

Elements associated with job-related illnesses and exposures include the following:

• In accordance with state and federal requirements, keep records of medical evaluations, immunizations, screening and test results, and work-related illnesses or exposures.
• Establish a readily available mechanism for personnel to get advice about illnesses they may acquire from or transmit to patients.
• Write protocols for addressing work-related and community-acquired infectious diseases and exposure incidents; steps should include notifying infection prevention and occupational health staff and recording such occurrences when appropriate.

Elements related to record keeping, data management, and confidentiality include the following:

• Keep individual records for all personnel, and maintain confidentiality at all times. Ensure that personnel have access to their individual records.
• Maintain individuals' confidentiality whenever data is made public (e.g., by releasing only aggregate data).
• Keep a personnel database that lets the hospital track immunizations, tests, and infectious-disease trends among personnel.
• Periodically review and assess aggregate data on personnel health.

Work Restrictions

The guideline also addresses work restrictions. It recommends developing policies on contact of personnel who have potentially transmissible conditions with patients. Such policies should address personnel responsibility for reporting illnesses and using the occupational health service, work restrictions, and clearance for return to work. People who have authority to relieve personnel of duty should be identified. Work exclusion policies should be nonpunitive. (Bolyard et al.)

Train Staff

Action Recommendation: Train and educate staff regarding infection prevention and control.

HICPAC's guideline on infection control in healthcare personnel recommends training and educating personnel, upon hire, annually, and as otherwise needed, on infection prevention and control issues appropriate to their work assignments. (Bolyard et al.) The hospital may also may also wish to supplement such education with informal strategies, such as posters, huddles, or informal walkrounds, and topic-specific campaigns.

The content and language of such training must be appropriate to the educational and literacy levels and language of personnel. Written policies and procedures on infection prevention and control in healthcare personnel should be readily available. (Bolyard et al.)

Topics to address may include the following (Siegel et al. "2007 Guideline"; Bolyard et al.; Siegel et al. "Management"):

• Disease transmission
• Conditions or treatments that may make patients or personnel more susceptible to infectious disease
• Consideration of all body fluids as potentially infectious
• The role of vaccination in protecting patients and personnel
• Hand hygiene
• Respiratory etiquette
• How to recognize and report patients with signs and symptoms of transmissible disease
• Steps to take until a diagnosis is established
• Standard and transmission-based precautions:
  
• The scientific rationale for precautions
• The importance of compliance
• Isolation
• The importance of cooperating with outbreak investigations
• Personal Protective Equipment (PPE) use
• Standards addressing infection prevention and control
• Prevention and control of tuberculosis (TB) and bloodborne pathogen infections
• MDRO risks and transmission
• MDRO prevention strategies
• Organizational experience with MDROs
• Occupational health issues:
  
• Why personnel screening and immunization are important
• Which personnel illnesses and exposure incidents to report
• Why it is important to report them
• How to report them
• Surveillance data
• Areas for improvement
• Other topics recommended by the infection preventionist

Local, state, or federal agencies often have specific requirements for the content, timing, or format of training on infection prevention and control.

Hand Hygiene Training Program, Bloodborne Pathogens Training Program, and Respirator Training Program include slide presentations and other training materials on these four topics.

Evaluating staff members' knowledge and use of appropriate practices may help inform future training. In fact, CDC's guideline on precautions and isolation states that it is necessary to periodically assess staff members' knowledge of and adherence to recommended practices. The organization can then determine future educational needs and provide feedback to staff. (Siegel et al. "2007 Guideline")

Educate Patients, Families, and Visitors

Action Recommendation: Educate patients, families, and visitors regarding infection prevention and control issues that are relevant to them.

The organization may wish to educate patients, family members, and visitors and give them materials on the following topics (Siegel et al. "2007 Guideline"):

• Hand hygiene
• Respiratory hygiene and cough etiquette
• Vaccination
• Other routine infection prevention strategies

If transmission-based precautions are necessary, the organization may provide education and materials on topics such as the following (Siegel et al. "2007 Guideline"):

• The rationale for the additional precautions
• Risks to household members
• Reasons for room assignment
• Staff members' use of PPE
• Directions for family members' and visitors' use of PPE

Use Standard and Transmission-Based Precautions

Action Recommendation: Monitor compliance with standard and transmission-based precautions.

Compliance with standard and transmission-based precautions, as outlined in HICPAC's standard on precautions and isolation, is crucial to preventing the transmission of infectious agents; however, it is also among the most challenging elements of infection prevention and control. Hospitals may wish to monitor compliance with precautions and isolation practices.Infection Control Unit Survey is an example of a tool that may be used to observe environmental conditions and care practices throughout the hospital.

Standard Precautions

Standard precautions should be followed during all patient encounters in all healthcare settings, according to HICPAC. Standard precautions include hand hygiene, PPE use, respiratory hygiene and cough etiquette, safe injection practices, and environmental and equipment management.

According to CDC, proper hand hygiene by healthcare workers is the most important practice for preventing HAIs. For more information, see the guidance article Hand Hygiene in the Healthcare Setting.

Healthcare workers must also wear appropriate PPE when indicated and adhere to other recommendations from the HICPAC guideline regarding their use. For example, staff should change gloves between patients but may also need to change gloves during the care of a single patient when moving from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face) (Siegel et al. "2007 Guideline"). For more information on the selection and use of PPE, see the guidance article Personal Protective Equipment.

Transmission-Based Precautions

Transmission-based precautions are used when a patient is known or suspected to be colonized or infected with a highly transmissible or epidemiologically important pathogen and standard precautions alone are not sufficient to prevent transmission.

Depending on the infectious agent, three types of transmission-based precautions—contact precautions, droplet precautions, or airborne precautions—are used. An appendix to the HICPAC guideline lists the precautions that are recommended for specific infections. In some cases, more than one type of transmission-based precaution may be necessary. Transmission-based precautions are always used in addition to—not instead of—standard precautions. (Siegel et al. "2007 Guideline")

Perform Surveillance

Action Recommendation: Perform surveillance of infectious diseases and related measures, and act on the findings if necessary.

Surveillance of infectious diseases and related outcomes and events can serve several purposes, including the following (APIC):

• Determining baseline and endemic infection rates
• Detecting clusters and outbreaks
• Evaluating the effectiveness of infection prevention measures
• Monitoring adverse outcomes to identify risk factors
• Targeting specific issues for performance improvement
• Observing practices (e.g., hand hygiene) to assess compliance
• Detecting diseases that must be reported to public health agencies
• Detecting organisms of epidemiologic importance (e.g., MDROs, TB)
• Ensuring compliance with the requirements of federal, state, and accrediting agencies
• Informing efforts to educate personnel
• Monitoring personnel injuries and identifying risk factors
• Detecting emerging infectious diseases or bioterrorist events
• Supplying data for facility risk assessments

Hospitals that use CDC's National Healthcare Safety Network (NHSN) methodology can use the standardized infection ratio (SIR) to compare their actual infection rates with expected rates based on aggregate national or state data. The rate of a specific type of infection that occurred at the organization is divided by the number of infections that would have been expected based on previous years of national or state data. An SIR greater than 1.0 indicates that more HAIs were observed than predicted, while an SIR less than 1.0 indicates that fewer HAIs were observed than predicted.

Designing a Surveillance Program

APIC suggests taking the following steps when designing a surveillance program (APIC):

Choose the surveillance methodology. Two basic surveillance methodologies exist, but many hospitals use a combination of the two. Total, or whole-house, surveillance tracks all HAIs in the facility's patient population. Some states mandate whole-house surveillance. Targeted surveillance often focuses on specific units, device-related infections, invasive procedures, or epidemiologically important organisms or a combination of the above. Applications that automate surveillance are available.

Define the population. The hospital may wish to focus on patients or personnel at high risk of infection or adverse outcomes.

Choose the indicators. Surveillance should measure outcomes (e.g., HAIs, sharps injuries), processes (e.g., hand hygiene compliance, environmental cleaning, antimicrobial prescribing), and other important events (e.g., occurrence of reportable diseases, admission of a patient with an MDRO). At least some indicators should focus on personnel.

Determine the time period. For uncommon events, the period must be long enough to make the data useful.

Identify case definitions. A case definition is a set of criteria used to determine whether an individual should be considered to have a specific disease or injury for the purposes of surveillance. CDC's NHSN offers case definitions for specific types of infections in acute care (see Resource List).

Determine which data elements to collect. Which data to collect depends on the indicator and the statistical measures that will be used for analysis. Examples include patient identifier, demographic information, unit, primary diagnosis, test results, infection type, and risk factors (e.g., procedure information, device usage information).

Select the statistical measures to use. Measures often used in surveillance include measures of frequency (e.g., rates, ratios, proportions), central tendency (e.g., mean, median), and dispersion (e.g., standard deviation) and percentiles. Hospitals should use the same measures as national surveillance systems whenever possible.

Identify methods for data collection and management. Data may be collected while the patient is still receiving care at the hospital or after discharge. A multitude of sources may be used, from medical records and laboratory reports to reports from other departments (e.g., occupational health, performance improvement).

Develop a surveillance report. To inform performance improvement activities, infection prevention professionals should develop a written report that interprets surveillance data and should distribute it to relevant individuals and departments. Tables, graphs, and charts may help illustrate the data and make it easier to understand.

Write a surveillance plan. The written surveillance plan should outline the surveillance program's purpose, goals, and objectives and the elements of the program. (APIC)

Prevent and Control MDROs

Action Recommendation: Use general and intensified measures, and coordinate with other healthcare organizations to address MDROs.

The HICPAC MDRO guideline includes two tiers of MDRO prevention and control measures. The first tier offers general recommendations for routine MDRO prevention and control, and the second describes intensified measures for use when an MDRO problem cannot be controlled through the use of measures in the first tier. The general and intensified measures address administrative steps and adherence monitoring, MDRO education, judicious antimicrobial use, surveillance, precautions to prevent transmission, environmental measures, and decolonization.

Following are some of the guideline's general recommendations regarding administrative measures and adherence monitoring; some of the other general recommendations are mentioned elsewhere in this guidance article (Siegel et al. "Management"):

• Make MDRO prevention and control an organizational priority. Provide administrative support and fiscal and human resources.
• Implement systems to report certain MDROs to administrative personnel and, if required, public health departments.
• Implement a multidisciplinary process to monitor staff adherence to standard and contact precautions.
• Implement systems to designate patients colonized or infected with a targeted MDRO, and notify receiving healthcare organizations before transfer of such patients.
• Support participation in local, regional, or national coalitions on MDROs.
• At least annually, give administrators and staff feedback on MDRO infections at the facility, including changes in prevalence and incidence, problem assessment, and performance improvement plans.

In conjunction with the 2015 CDC report that called for coordinated approaches to halt the spread of resistant organisms, the agency published resources and information on coordinated efforts to stop the spread of antibiotic resistance (see Resource List). Actions for healthcare facility administrators include the following (CDC "Making Health Care Safer"):

• Implement systems to alert receiving facilities when transferring patients who have drug-resistant germs.
• Review and perfect infection control actions within the facility.
• Get leadership commitment to join HAI and antibiotic resistance prevention activities in the area.
• Share data about antibiotic resistance and other HAIs with the public health department.
• Make sure clinical staff have access to prompt and accurate laboratory testing for antibiotic-resistant germs.

Use Antimicrobials Wisely

Action Recommendation: Implement an antimicrobial stewardship program.

According to the IDSA/SHEA guidelines on implementing an antimicrobial stewardship program, the primary goal of such a program is "to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use," such as the selection of pathogenic organisms, the emergence of resistance, and toxicity. Together, effective antimicrobial stewardship and a comprehensive infection control program have been shown to curtail the emergence and transmission of resistant bacteria. Comprehensive programs reduce antimicrobial use by 22% to 36%, reducing costs and the potential for resistance.

The hospital should have a multidisciplinary antimicrobial stewardship team. Core members include an infectious-diseases physician and a clinical pharmacist who has training in infectious diseases; they should be compensated for their time. Ideally, other members include a clinical microbiologist, an information systems specialist, an infection prevention professional, and the hospital epidemiologist. The infectious-diseases physician typically directs the program or codirects it with the clinical pharmacist.

The program must have sufficient infrastructure and administrative support to measure antimicrobial use on an ongoing basis. The team should collaborate with the infection prevention and pharmacy and therapeutics committees. The clinical microbiology laboratory should provide patient-specific information on cultures and susceptibilities and aid surveillance of and outbreak investigations involving resistant organisms.

Two proactive strategies may serve as the foundation for the program; the hospital may use one or both. In the first, the infectious-diseases physician or clinical pharmacist prospectively audits antimicrobial use and gives direct feedback to the prescriber. In the second, the hospital restricts the formulary or requires preauthorization (or both). If the hospital uses preauthorization in an effort to curb the use of certain antimicrobials, it should also monitor general trends in antimicrobial use to ensure that prescribers have not simply switched to an alternative that is equally or more prone to resistance.

The following measures may supplement the core proactive strategies (Dellit et al.):

• Education of personnel
• Development of evidence-based guidelines and clinical pathways
• Use of antimicrobial order forms
• Use of combination therapy in appropriate situations (e.g., empirical therapy in critically ill patients who are at risk for infection with MDROs)
• Streamlining or de-escalation of therapy on the basis of culture results
• Individualized optimization of dosing
• Development of a systematic plan for switching from parenteral to oral antimicrobials whenever possible

Technology may also aid antimicrobial stewardship. Electronic health record, computerized provider order entry, and clinical decision support systems may incorporate patient-specific information on cultures and susceptibilities, liver and kidney function, or allergies, plus drug interactions and costs. Computer-based surveillance may help the hospital more effectively target interventions, track resistance, and identify HAIs and events.

The hospital should measure the effectiveness of the antimicrobial stewardship program. The evaluation should include both process measures (e.g., antimicrobial usage patterns) and outcome measures (e.g., antimicrobial resistance patterns). (Dellit et al.)

The IDSA/SHEA guidelines, CDC's Get Smart for Healthcare campaign, and the SHEA/IDSA/PIDS policy statement (see Resource List) provide additional guidance and tools.

Control Outbreaks

Action Recommendation: Develop procedures for responding to outbreaks.

Outbreaks are an increase in the occurrence of an event beyond what is expected. A corollary is that just one case of an uncommon microbe or event (e.g., healthcare-associated legionellosis) may represent an outbreak. Often, many factors contribute to an outbreak. Examples include lapses in infection prevention or clinical practices, defective or contaminated devices or products, and infected or colonized personnel. (APIC)

Surveillance may help detect outbreaks, but most often, observant personnel or infection preventionists are the ones to recognize them. (APIC)

Swift recognition and action is critical. HICPAC's guideline on precautions and isolation includes a table that lists conditions, signs, and symptoms that warrant transmission-based precautions even before diagnosis or confirmation. For example, the guideline states that pending confirmation or diagnosis, contact precautions are warranted if an incontinent or diapered patient has acute diarrhea with a likely infectious cause. (Siegel et al. "2007 Guideline")

Most local and state health departments require healthcare organizations to notify public health officials as soon as an outbreak is suspected. If the outbreak involves a contaminated or defective product, device, or medication, CDC and FDA should also be notified. (APIC)

Both outbreaks and clusters (small outbreaks) must be investigated promptly. The goal of outbreak investigations is to identify contributing factors and address them, in order to end the outbreak and prevent future occurrences. Outbreak investigations must be standardized, although steps may need to be performed out of order or repeated. The steps to perform in an initial outbreak investigation are as follows (APIC):

• Confirm that it is truly an outbreak (e.g., not simply an increase in positive cultures). Steps may include reviewing surveillance or microbiology reports.
• Tell key people (e.g., administrators, the microbiology laboratory, public health officials).
• Review the literature to identify possible sources of infection and investigative methodologies.
• Establish an initial case definition that is narrow enough to focus the investigation but broad enough to capture most cases.
• Choose a methodology for finding cases, which is likely to involve referring to multiple sources (e.g., reviewing laboratory or surveillance records, talking with personnel).
• Prepare an initial line list (a list of cases that includes elements such as signs and symptoms, medications, procedures, locations where the patient has received care, and patient risk factors) and an epidemic curve (a graph that plots cases according to the time of onset).
• Observe patient care activities related to the event.
• Decide whether to conduct environmental sampling, which can be expensive and difficult to perform effectively but can sometimes provide helpful information.
• Implement initial control measures, and create a plan to ensure compliance.

If the outbreak continues after initial measures have been implemented, a follow-up investigation may be necessary. Steps to perform during the follow-up investigation are as follows (not all steps may be necessary) (APIC):

• Refine or expand the case definition based on lessons learned from the initial cases.
• Continue finding cases and performing surveillance. Continue surveillance for a substantial period of time (e.g., one month) after it appears the outbreak has ended.
• Regularly review outbreak control measures, including personnel compliance.
• Decide whether to perform an analytic study (e.g., a case control study).

Organizations should also plan for pandemics of infectious diseases. For more information on planning for pandemics, see the guidance article Emergency Management.