. Preface. American Hospital Association. Association for Practitioners in Infection Control. Centers for Disease Control (cnc). GAO/I.

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2 . Preface The Centers for Disease Contro estimates that about 5 percent of a patients who enter hospitas contract at east one infection during their stay. Hospita-based infections resut in increased patient suffering and sometimes death; onger hospita stays; and increased heath care costs. Effective infection contro programs can reduce the number of nosocomia infections, and researchers have estimated that such programs can more than pay for themseves by reducing patients engths of stay and the reated costs of treating infections. We have prepared this isting of eements that experts consider necessary for effective hospitabaaed infection contro programs in order to share it with infection contro practitioners and program directors and other interested parties. We deveoped the isting to assess the content of infection contro programs in the Departments of Veterans Affairs (VA) and Defense hospitas and to compare such programs with those in nonfedera hospitas. We found that federa and nonfedera hospitas were simiar in their use of the eements and many hospitas use a significant number of them. For exampe, our survey of 443 nonfedera hospitas showed that 42 of the 56 eements were being used by over 70 percent of the hospitas when such use was appropriate. The 56 eements refect current thinking on basic infection contro program activities. We deveoped these eements by first consuting with officias of the organizations and the individua that foow: American Hospita Association. Association for Practitioners in Infection Contro. Centers for Disease Contro (cnc). For more detais on our comparison of VA and nonfedera hospitas infection contro programs see our report, Infection Contro: VA Programs Are Comparabe to Nonfedera Programs but Can Be Enhanced (GAO/HRD-90-27). Our report on the comparison of Department of Defense and nonfedera hospitas wi be pubished ater this year. Page 1 GAO/I.RD-99-25

3 Preface Joint Commission on Accreditation of Heathcare Organizations. The Society of Hospita Epidemioogists of America. Robert W. Haey, M.D., who directed cnc s Study on the Efficacy of Nosocomia Infection Contro (SENIC).? We discussed the activities these officias thought were necessary for an effective infection contro program and worked with cnc officias to compie a comprehensive ist of eements. The ist was sent to the above organizations (except cnc) as we as the foowing organizations: American Pubic Heath Association. The Association of Operating Room Nurses, Inc. Association of State and Territoria Heath Officias. Surgica Infection Society. We asked each to indicate which eements coud be considered minimum requirements for an effective infection contro program. Prom their responses, we deveoped a ist of the eements that six or more agreed were minimum requirements and, subsequenty, discussed these with cnc infection contro experts. Using existing Joint Commission standards, pubished studies demonstrating the effectiveness of an eement, and CDC S judgment as to whether the eement woud be widey supported by infection contro experts, we arrived at a fina ist of 56 eements. These eements focus on the surveiance activities of an infection contro program. We beieve that these eements shoud be usefu to both practitioners and hospitas in starting or evauating infection contro programs. However, the eements indicate ony whether an infection contro program invoves certain activities and shoud not be used by themseves to assess the program s effectiveness. Other important determinants of a In thii study, CL% evauated the impact of surveiance and contro activities on nosocomia infections in a sampe of hospitas. Page 2 GAO/HRD-99-25

4 , >. Preface program s effectiveness incude hospita and program priorities, avaiabiity of data to identify probems, and, most significanty, how we infection contro activities are carried out by hospita staff. The fied of infection contro is a dynamic one. Better ways to ascertain the risk of nosocomia infections and reduce infection rates continue to be found. Our hope is that these basic eements wi be expanded and modified to refect further deveopments in infection contro program knowedge and practices. Asuc.sLk -e \ OTti Lcud Lawrence H. Thompson Assistant Comptroer Genera for Human Resources Programs Page 3 GAO/HRD-90-25

5 Basic Eements of an Infection Contro Program Appicabiity the Eements of The basic eements cited in this pamphet are appicabe ony to acute-care hospitas having 50 or more beds. Infection contro programs for hospitas with ess than 50 beds shoud entai many of the same types of activities but coud be ess structured than programs for arger faciities. Aso, infection contro programs in extended care faciities may be somewhat different because the infection risks, avaiabiity of diagnostic tests, and organizationa structure may not be the same as in acute-care hospitas. Use of the Basic Eements The basic eements are divided into five groups: genera program eements, boodstream infections, pneumonia, surgica wound infections, and urinary tract infections. The genera group incudes 14 eements that appy to a hospitas and address program structure, appicabe surveiance activities, and contro activities. The remaining four groups of eements are organized by the four major sites of infection and address surveiance activities (identification, anaysis, and reporting) specific to each site. The eements aow for both tota and targeted surveiance. A program performing tota surveiance monitors a four major sites of infection in every hospita patient on either a periodic or continuous basis. A program that targets surveiance identifies the areas of highest infection risk or concern and focuses its attention on such areas; for exampe, patients in the intensive care unit or a boodstream infections. The specific eements appicabe to an infection contro program depend on whether the program uses tota or targeted surveiance: Tota surveiance-a five groups of eements woud be used, however, a few individua eements within the groups may not be appicabe (see the basic eements). Page 4 GAO/DRD-90-26

6 Basic Eements of an Infection Contro Program Targeted surveiance-the genera eements woud be used, and, depending on which site(s) of infections are being targeted in the high risk groups, other appropriate groups of eements woud be used (i.e., boodstream, pneumonia, surgica wound, or urinary tract). Athough the basic eements pace emphasis on surveiance activities, an infection contro program cannot be effective without contro activities. We incuded in our ist ony the broad categories of contro functions because contro activities, unike surveiance activities, are performed not ony by the infection contro staff but by other hospita personne. cnc has pubished detaied recommendations on procedures to be foowed by providers to prevent infections. Further, contro activities that (1) are carried out by the program and (2) are beneficia to a hospitas are difficut to specify because the appropriate contro activities depend heaviy on the surveiance findings and the circumstances within the individua hospita. For exampe, if a program finds it has a high rate of boodstream infections reated to intravenous catheters, the appropriate contro activity coud be to revise the hospita poicy on changing intravenous catheters or provide inservice training for residents or nurses responsibe for inserting or changing the catheters. The ist of eements that foows is not a incusive; the eements isted form a basic rather than an optima program. Therefore, the eements shoud be used in conjunction with other standards, such as the Joint Commission s accreditation standards and CDC S guideines. Page 6 GAO/ERD-90-26

7 Genera Eements (These appy to a hospitas) Structure G. The hospita has at east a part-time infection contro practitioner. G2. The hospita has a physician who supervises or consuts in the infection contro program and has taken at east one training course in hospita infection contro. G3. - The hospita has a mutidiscipinary infection contro committee. G4. Permanent membership on the commrttee incudes representation from the foowing: *hospita administration, *microbioogy aboratory (if one exists), *medica staff, and *nursing service. G5. The committee meets at east everv 2 months Surveiance Activities G6. The infection contro program performs surveiance for at east one of the four major infection sites (boodstream, pneumonia, surgica wound, and urinary tract). G7. The hospita s infection contro program has written standardized criteria (definitions) for nosocomia infections at specific sites. GE. The infection contro program has a system to detect and contro outbreaks of infections. Contro Activities G9. The hospita s infection contro program assists in deveoping and revising hospita departments poicies and procedures as they reate to infection contro issues. GIO. The hospita s infection contro program assists in deveoping a system for reporting infections or infection exposures of empoyees. _ Page 6 (continued) GAO/EItD-90-25

8 . k * Genera Eements Structure Gi. The hospita s infection contro program assists in identifying and deveoping infection contro topics for orientation casses. G12. The hospita s infection contro program assists in identifying and deveoping infection contro topics for in-service training. G13. The hospita s infection contro program monitors or assists in monitoring the hospita staff s compiance with specific patient care practices, such as aseptic techniques during intravenous catheter insertion and maintenance of insertion sites. G14. Infection contro practitioners and registered nurses on hospitas units have written authority to impement isoation procedures in an emeraencv without a chvsician s order. Page 7 GAO/m-90-25

9 Bood&rem Infections, i identification B. A hospita s infection contro program uses at east one of the foowing case-finding approaches to identify boodstream infections either in a patients or in a subset of patients:? Review resuts of bood cutures in a patients in target popuation. Appicabiity surveiance Tota to type Target Review a patients charts in target popuation. Review a patients fever charts in target popuation. B2. Duriig the surveiance period, a hospita s infection contro program performs an acceptabe case-finding approach (previous criterion) on an average of every 3 daysa 83. In their case-confirmation effort, infection contro staff perform at east one of the foowing activities if they do not review a patients charts in target popuation as a case-finding activity: Review resuts of bood cutures in patients in target popuation, identified through case finding (if they do not review resuts of bood cutures in a patients in target popuation as a case-finding activity). Review patients charts in target popuation identified through case finding. Anaysisb B4. The infection contro program has deveoped initia baseine rates for nosocomia boodstream infections within the hosdta. B5. Infection contro staff anayze nosocomia boodstream infection data bv bathoaen. B6. Infection contro staff anayze data on nosocomia boodstream infections by whether or not patient had periphera and/or centra intravenous (IV) cannuation. 87. Infection contro staff anayze nosocomia infection data bv ward. boodstream (continued) Page 8 GAO/ERD-90-26

10 . Boodstream Infections Repotting B8. Infection contro staff report summarized/ anayzed data on nosocomia boodstream infections to the infection contro committee. B9. Infection contro staff report summarized/ anayzed data on nosocomia boodstream infections to the supervisor of the IV therapy team, if one exists. BO. Infection contro staff report summarized/ anayzed data to the ward supervisors or head nurses. Appicabiity surveiance Tota to type Target amportant infection contro probems may require case finding more frequenty than every 3 days. bthe proper anaysis of infection data requires cacuation of infection rates in specific patient risk groups, as we as frequency distributrons and ine istings of the infections. If infection rates are to be usefu for estimating infection risks in patient groups, appropriate data shoud be coected; for exampe, if boodstream infections caused by intravenous catheters are being anayzed, then both the number of patients with Intravenous catheters and the number of those patients who deveop boodstream infections are needed. Page 9 GAO/ERD-90-25

11 Pneumonia Identification P. A hospita s infection contro program uses at east one of the foowing case-finding approaches to identify pneumonia either in a patients or in a subset of patients: Appicabiity surveiance Tota to type Target Review a patients Kardexes in target popuation. Ask nurses about signs or symptoms of a respiratory infection in a patients in target popuation. Review a patients charts in target popuation. P2. During the surveiance period, a hospita s infection contro program performs an acceptabe case-finding approach (previous criterion) on an average of every 3 days.a P3. In their case-confirmation effort, infection contro staff perform at east one of the foowing activities if they do not review a patients charts in target popuation as a case-finding activity:. Review ab and -ray resuts for evidence of pneumonia in patients in target popuation, identified through case finding (if they do not review ab and -ray resuts in a patients in target popuation as a case-finding activity). Review patients charts in target popuation identified through case finding. - Anavsisb P4. The infection contro program has deveoped initia baseine rates for nosocomia pneumonia within the hosprta. P5. Infection contro staff anayze data on nosocomia by pathogen. pneumonia P6. Infection contro staff anayze data on nosocomia pneumonia by whether or not patient was on a ventiator, if target popuation incudes ventiator patients. P7. Infection contro staff anayze data on nosocomia pneumonia bv ward. Page 10 GAO/EItD-99-25

12 Pneumonia Appicabiity surveiance Tota to type Target P8. Infection contro staff anayze data on nosocomia pneumonia by whether or not patient had surgery, if target popuation incudes surgica patients. Reporting P9. Infection contro staff report summarized/ anayzed data on nosocomia pneumonia to the infection contro committee. PIO. If target popuation incudes ventiator patients, infectron contro staff report summarized/anayzed data on nosocomia pneumonra to the respiratory therapy department, if one exists. P. Infection contro staff report summarized/ anayzed data on nosocomia pneumonia to the ward supervisors or head nurses. amportant infection contro probems may require case finding more frequenty than every 3 days. bthe proper anaysis of infection data requires cacuation of infection rates in specific patient risk groups, as we as frequency distnbutions and ine istings of the infections. If Infection rates are to be usefu for estimating infection risks in patient groups, appropriate data shoud be coected; for exampe, if boodstream infections caused by intravenous catheters are being anayzed, then both the number of patients with intravenous catheters and the number of those patients who deveop boodstream infections are needed. Page 11 GAO/JBD-99-25

13 Surgica Wound Infections Identification S. A hospita s infection contro program uses at east one of the foowing case-finding approaches to identify surgica wound infections either in a surgica patients or in a subset of surgica patients: Review resuts of gram stains and cutures of wounds in a patients in target popuation, and ask nurses about signs or symptoms of surgica wound infections in a patients in target popuation. Appicabiity surveiance Tota to type Target Review a surgica patients Kardexes in target popuation. Review a surgica patients charts in target popuation. s2. During the surveiance period, a hospita s infection contro program conducts case finding using an acceptabe approach (previous criterion) on an average of every 3 days.a s3. In their case-confirmation effort, infection contro staff perform at east one of the foowing activities if they do not review a surgica patients charts in target popuation as a case-finding activity: Review resuts of gram stains and wound cutures for patients in target popuation identified through case finding (if they do not review gram stains and wound cutures for a patients in target popuation as a case-finding activity). Review surgica patients charts in target popuation identified through case finding. Ask nurses about signs or symptoms of surgica wound infections in patients in target popuation identified through case finding (if they do not ask nurses about signs or symptoms of surgica wound infections in a patients in target popuation as a case-finding activity). Anavsisb s4. The infection contro program has deveoped initia baseine rates for suraica wound infections in the hosoita. s5. Infection contro staff anayze surgica wound infection data by surgeon. x (continued) Page 12 GAO/HRD-90-25

14 . F t Surgka Wound Infections S6. Infection contro staff anayze surgica infection data by type of wound cassification (e.g., cean, cean-contaminated, contaminated, and dirty). s7. Infection contro staff anayze surgica wound infection data by pathogen. S8. Infection contro staff anayze surgica wound infection data bv ward. Reporting s9. Infection contro staff report summarized/ anayzed data on surqica wound infections to the infection contro committee. SO. Infection contro staff report summarized/ anayzed data on surgica wound infections to the surgica compications committee, if one exists. S. Infection contro staff report summarized/ anayzed data on surgica wound infections to the chief of the surgica service. s12. Infection contro staff report summarized/ anayzed data on surgica wound infections to the operating room supervisor. s13. Practicina suraeons receive suraeon-specific infection rates. Appicabiity surveiance Tota?mportant infection contro probems may require case finding more frequenty than every 3 days to type Target bthe proper anaysis of infectron data requires cacuation of infection rates in specific patient risk groups, as we as frequency distributions and ine istings of the infections. If infection rates are to be usefu for estimating infection risks in patient groups, appropriate data shoud be coected; for exampe, if boodstream infections caused by intravenous catheters are being anayzed, then both the number of patients with intravenous catheters and the number of those patients who deveop boodstream infections are needed. Page 13 GAO/EtRD-90-25

15 Urinary Tract Infections Identification U. A hospita s infection contro program uses at east one of the foowing case-finding approaches to identify urinary tract infections either in a patients or in a subset of patients: Review a patients Kardexes in target popuation. Review resuts of urine cutures in a patients In target popuation, and ask nurses about signs or symptoms of a urinary tract infection in a patients in target popuation. Appicabiity surveiance Tota to type Target Review a patients charts in target popuation. u2. During the surveiance period, a hospita s infection contro program performs an acceptabe case-finding approach (previous criterion) on an average of every 3 days.a u3. In their case-confirmation effort, infection contro staff perform at east one of the foowing activities if they do not review a patients charts in target popuation as a case-finding activity: Review resuts of urine cutures in patients in target popuation, identified through case finding (if they do not review ab resuts of urine cutures in a patients in target popuation as a case-finding activity). Review patients charts in target popuation identified throuah case findina. Anaysisb u4. The infection contro program has deveoped initia baseine rates for nosocomia urinary tract infections within the hospita. u5. Infection contro staff anayze data on nosocomia tract infections by pathogen. U6. Infection contro staff anayze data on nosocomia tract infections by ward. Reoortina urinary urinary U7. Infection contro staff report summarized/ anayzed data on nosocomia urinary tract infections to the infection contro committee. Page 14 GAO/HRD-90-25

16 Urinary Tract Infections U8. Infection contro staff report summanzed/ anayzed data on nosocomia urinary tract infections to the ward supervisors or head nurses. Appicabiity surveiance Tota to type Target 9mportant infection contro probems may requrre case finding more frequenty than every 3 days. bthe proper anaysis of infection data requires cacuation of infection rates in specific patient risk groups, as we as frequency distributions and ine istings of the infections. If infection rates are to be usefu for estimating infection risks in patient groups, appropriate data shoud be coected; for exampe, if boodstream infections caused by intravenous catheters are being anayzed, then both the number of patients with intravenous catheters and the number of ( those patients who deveop boodstream infections are needed. Page 16 GAO/EKED-90-25

17 Acknowedgements We wish to thank the foowing organizations and individua for their counse as we formuated and attempted to obtain consensus on the basic eements of an effective infection contro program. American Hospita Association. American Pubic Heath Association. The Association of Operating Room Nurses, Inc. Association for Practitioners in Infection Contro. Association of State and Territoria Heath Officias. Centers for Disease Contro (cnc).. Joint Commission on Accreditation of Heathcare Organizations. The Society of Hospita Epidemioogists of America. Surgica Infection Society.. Robert W. Haey, M.D., who directed CDC Study on the Efficacy of Nosocomia Infection Contro (SENIC). We particuary want to acknowedge James 0. Mason, M.D., Assistant Secretary for Heath, who supported us in this effort, and the hospita infection contro experts within the Center for Infectious Diseases at cnc, who provided advice throughout the proje&. In addition, we woud ike to thank the infection contro practitioners in the Department of Veterans Affairs and Department of Defense and the sampe of nonfedera hospitas who responded to our questionnaire on their programs activities. We sincerey appreciate their efforts to compete the questionnaire and to give us response rates of 100,97, and 85 percent, respectivey. SENIC evauated the impact of surveiance and contro activities on nosocomia infections in a sampe of hospitas. Page 16 GAO/HRD-90-25

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