Modern hospital infectioncontrol programs first began in the 1950s in England, where the primary focus of theseprograms was to prevent and control hospital-acquired staphylococcal outbreaks. In 1968,the American Hospital Association published "Infection Control in the Hospital,"the first and only standards available for many years. At the same time, the CommunicableDisease Center, later to be renamed the Centers for Disease Control and Prevention (CDC),began the first training courses specifically about infection control and surveillance. In1969, the Joint Commission for Accreditation of Hospitals--later to become the JointCommission on Accreditation of Healthcare Organizations (JCAHO)--first required hospitalsto have organized infection control committees and isolation facilities.
In the 1970s, infection control underwent a growth spurt. In 1970, fewer than 10% of UShospitals had an infection control program. By 1976, more than 50% of US hospitals had aversion of an infection control program, including trained nurses to perform activesurveillance. In 1972, the Hospital Infections Branch at the CDC was formed and theAssociation for Practitioners in Infection Control was organized. By the close of thedecade, the first CDC guidelines were written to answer frequently asked questions andestablish consistent practice.
Infection control underwent a midlife crisis in the early 1980s. The cost value ofinfection control programs (e.g., surveillance) was questioned. Then in 1983, acombination of factors affecting healthcare impacted common infection control practice.The first was the adoption of a fixed-price prospective payment system based ondiagnostic-related groups (DRGs), which resulted in widespread cost-containmentinitiatives to non-revenue producing hospital services. Infection control was oftenincluded. Quickly it was discovered that 56% of DRGs did not allow for any complicationsor comorbidity. Further analysis demonstrated that only 5% of costs to treat nosocomialinfections would be reimbursed to hospitals. The fallout from prospective payment meantsicker patients were admitted into hospitals since less ill patients were treated on anoutpatient basis or discharged earlier--a trend in healthcare we continue to see today.The second and certainly most significant factor influencing infection control at the timewas the advent of acquired immunodeficiency syndrome (AIDS). The human immunodeficiencyvirus (HIV) has taken an enormous toll in terms of loss of life and productivity. Forinfection control professionals (ICPs), HIV has been a challenge for education, riskreduction and resource utilization.
In 1985, the Study of the Efficacy of Nosocomial Infection Control (SENIC) project waspublished, validating the cost-benefit of infection control programs. Data collected in1970 and 1976-1977 suggested that one-third of all nosocomial infections could beprevented if all the following were present:
Infection control in the 1990s was influenced by the reform of the healthcare systemwhen managed care networks became the preferred method for delivery of healthcare.Infection control programs had to encompass not only hospitals but also the long-term carefacility, home health/hospice, rehabilitation facilities, free-standing surgical centers,and physician office practices. A dramatic shift in patient care practices occurred asgreater than 65% of surgery cases were operated on in an outpatient setting. Issues thatwill continue to impact infection control programs into the new millennium are achallenging combination of cost and clinical factors and include decreasing reimbursement,increasing cost to treat infections, and financial impact of implementing new governmentregulations (Table 1).
From the beginning, ICP has been the central figure in the infection control program.The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) hassurveyed ICPs approximately every five years with a task analysis to determine the scopeof practice for developing a national infection control certification exam. Resultssuggest that regardless of the structure or hierarchy of the healthcare system, today'sICP needs knowledge of epidemiology statistics, patient care practices, occupationalhealth, sterilization, disinfection, and sanitation, infectious diseases, microbiology,education and management. The major responsibilities for ICPs to oversee includesurveillance, specific environmental monitoring, continuous quality improvement,consultation, committee involvement, outbreak and isolation management, regulatorycompliance and education. To plan, coordinate, and succeed in fulfilling theseresponsibilities, many ICPs have to redefine their roles. More ICPs are becoming managersby creating multidisciplinary support teams to carry out many of the functions.
In addition to the ICP, healthcare systems should have an identified infection controlcommittee chairperson. This position is usually filled by a person who is a physician orwho has a doctoral degree. The JCAHO standards place an emphasis on documenting thespecific epidemiologic and infection control training of this individual. In largeacademic settings, a well-trained hospital epidemiologist can provide clinical andepidemiologic consultation. However, to promote open discussion, this individual shouldnot necessarily be the infection control chairperson.
In large community hospitals, infection control consultation is usually provided by aninfectious diseases specialist who is knowledgeable about appropriate drug treatment,prophylaxis and pathology but is not formally trained in epidemiology or infectioncontrol. The small community hospital often does not have an infectious disease physicianat all. In these cases, the infection control committee chairperson will usually be from aspecialty area such as pathology/laboratory, surgery or medicine. In all areas, it is theICP who must critically lead the infection control program through day-to-day activities.
The JCAHO Standards state the goal for healthcare organizations' infection controlprograms is to identify and reduce risks of infections in patients and healthcare workers.Furthermore, there must be a functioning program coordinating all activities related tosurveillance, prevention, and control of infections. Many healthcare organizations usethese JCAHO standards as a framework upon which to build their infection control programs.The goal of an effective infection control program must be to then improve clinicaloutcomes using a multidisciplinary team approach.
Across the spectrum of today's healthcare, profits are decreasing. To keep healthcaresystems viable, costs must be cut to increase the profit margin. Infection controlprograms need to demonstrate their value to their organizations. Therefore, the secondgoal should be cost control and reduction. Cost strategies may target products, injuries,or nosocomial infections. The infection control professional must examine clinicalpractices with unproven value for infection prevention and control in patients or staff.Activities that do not add value should be eliminated. ICPs should standardize productselection when at all possible. Cost savings and reductions should be integrated intoreports: the goal is to balance quality and costs.
Goals of the infection control program need to be incorporated into the missionstatement of the facility. A mission statement should tell who you are, what you do, andshould communicate a clear view of purpose and set a strategy for accomplishing the goals.The University of North Carolina Healthcare System Infection Control Program missionstatement is as follows: "Hospital Epidemiology is a department with expertise ininfection control and related disciplines. Our mission is to promote a healthy and safeenvironment by preventing transmission of infectious agents among patients, staff andvisitors. This will be accomplished in an efficient and cost effective manner by acontinual assessment and modification of our services based on regulations, standards,scientific studies, internal evaluations and guidelines." The mission statementshould communicate why we are in the business of healthcare epidemiology and infectioncontrol.
Today, infection control is well established in the US Most healthcare organizationshave had an existing infection control program. The challenge then is not developing aninfection control program anew, but a more difficult task of reorganizing an existingprogram.
The first step should be to make an assessment of the current infection controlprogram. This review will have to include any new customers for your service resultingfrom any mergers and acquisition (e.g., home health, physician offices practices,ambulatory care surgical centers) involving the healthcare organizations. ICPs shouldassess the infection control program for compliance with written standards and guidelines,areas that need improvement and available resources. ICPs can begin by systematicallyreviewing the most current regulatory standards and guidelines.
Review standards from regulatory agencies (e.g., JCAHO, Occupational Health andSafety Administration [OSHA], and Healthcare Financing Administration [HCFA], long-termcare and state health department) to ensure compliance with requirements for accreditationor licensure. Make lists of any practices that the institutional policy is not incompliance with. The current JCAHO standards require an evaluation of virtually every areaof the facility from an infection control perspective for risks, prevention and control.Guidelines written by organizations specializing in infection control (e.g., APIC,Society for Healthcare Epidemiology of America [SHEA], CDC)--although not regulatory--areconsidered standards of care by regulatory surveyors. These guidelines should be followedunless newer literature provides scientific rational for not using them. ICPs should besure that they are using the most current guidelines available. The Internet is useful forthis purpose. The North Carolina Statewide Program for Infection Control and Epidemiology(SPICE) maintains a web site on the Internet with links to guidelines and recommendations,plus many infection control resources at www.unc.edu./depts/spice/.
Program assessment should be made internally and externally for available resources andareas for improvement. An internal resource may be a well-trained certified ICP or atrained epidemiologist with funding to provide consultation to the infection controlprogram. An external resource could be a microbiology laboratory capable of rapidtuberculosis identification. An internal self-assessment of needs might evaluate previousquality improvement projects, surveillance data, or relevant sentinel events. Externalneeds may be assessed by surveys or questionnaires of hospital staff or patientsatisfaction. The value of making assessments is to be able to prioritize the greatestneeds to determine the necessary resources. From that information, an infection controlplan can be developed.
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