. Masks made of other material such as wool, gauze, or paper are not considered effective. The use of masks is indicated for many situations and is present for both the protection of the patient and the healthcare worker.  Gloves are another set of necessary barrier when working with patients with a communicable disease. Staff should wear non-sterile gloves when caring for this type of patient while when working in surgery or immuno-compromised patients, gloves used should be sterile[58]. Again, gloves are used for protection of both the patient and healthcare provider.

 

Injection Practices

Transmission of blood borne pathogens are often the result of unsafe injection methods. It is recommended that all staff are aware that they should decrease unnecessary injections, to always use a sterile needle and syringe, and to dispose of the used needle and syringe in an appropriate manner, i.e. the use of a sharps container and biohazard disposals[59].

 

Equipment Safety

Another common mode of transmission of infection is through equipment and environmental causes. Though it may appeal to common sense, it is necessary that the hospital environment is thoroughly cleaned often. The hospital can be divided into four zones where different cleaning procedures can be followed. In zone A, there are no patients in this area and normal cleaning can be used. In zone B, patients are present but do not have an infection nor are susceptible to infection. Zone B should be cleaned in a manner that does not raise dust and a detergent solution may be used to improve the cleaning. In zone C, patients are infected and isolated and in zone D, patients are often highly susceptible to infection and are isolated[60]. These areas must be cleaned with a detergent or antiseptic solution and different cleaning equipment must be used for different rooms.  Another important way to keep the equipment and environment safe is to disinfect through the use of other compounds than those used for cleaning. These compounds are usually non-volatile, remain safe for the patient and staff, and should be effective for a short time frame. Disinfection can be categorized as high, intermediate, or low. Under high-level disinfection, all microorganisms should be eliminated with the exception of heavy bacterial spore counts. Under intermediate disinfection, most bacteria and viruses are killed but not all spores are killed. Finally, in low-level disinfection, only some microorganisms are killed with some more resistant species escaping destruction[61]. One last way to ensure equipment safety is sterilization, which is destruction of all microorganisms. Sterilization can be achieved through both mechanical and chemical processes[62]. While equipment and device disinfection and sterilization is critical, it is also crucial that all personnel are trained properly in the use of the equipment and device and know contacts for any malfunctions in such equipment.

 

Isolation

While all of the infection control methods deal with physical objects, isolation of the patient also plays a critical role in infection control. The isolation of an infected patient can often prevent the spread of disease and also protect the patient from acquisition of other infections[63]. Isolation policy may vary slightly between hospitals but patient are usually evaluated before being placed under isolation.

 

Surveillance and Infection Control

Surveillance has been instituted for many years since the rise of nosocomial infections in the United States. A majority of hospitals have their own surveillance systems and some hospitals voluntarily report their findings to the CDC and the NNIS report is written to give other hospitals an idea of how well their infection control systems are working. Surveillance within the hospital can be gathered in several ways, they are:

 

Hospital-wide Surveillance

This is an exhaustive method that keeps track of every patient and almost all outbreaks are detected very early. This type of surveillance also records different types of infections and may help the healthcare worker to clearly identify the clusters of infection and to formulate a plan to deal with an emerging infection[64][65]. However, this approach is usually very labor-intensive and costly as it requires meticulous data gathering.

 

Surveillance by Objective/Priority-Directed Surveillance

This approach to surveillance is becoming more common for most hospitals and is a priorities-based approach to data gathering. That is, the hospital determines which diseases or infections are of particular importance to them and those are the ones that have extensive information gathered about them. The determination of which infections to follow most closely could be based on severity of disease, total mortality/morbidity of the disease, frequency of the infection, length of stay, and cost of treating the infection[66]. However, with this type of approach, there is a less broad coverage of data and certain disease clusters may be missed by the surveillance team.

 

Targeted Surveillance

Similar to objective-based surveillance, targeted surveillance gather data based on the site, unit, outbreak, or in a rotating manner. In site-based, data is gathered based on which types of sites the infection occurred at, such as a surgical site or different organ systems[67]. Unit-based surveillance measures more high risk areas and may target a certain problem area in the hospital for education and follow up[68]. Unit-specific surveillance may help to identify infection control personnel that require more training. Rotating surveillance is to study a particular unit periodically[69]. This type of surveillance is time efficient and cost-effective but can also lead to missing of clusters of disease. Finally, outbreak based surveillance is targeted just to specific outbreaks in a certain period of time[70]. This approach should always be combined with other approaches as they do not provide a general view of infection control in the hospital.

 

Infection Control Case Study: The Cleveland Clinic Foundation[71][72]

Accredited by the JCAHO, the Cleveland Clinic Foundation (CCF) is one of the major hospital systems within the Cleveland, Ohio area. Besides a main campus, CCF also has numerous regional hospitals and outpatient clinics. In the main campus, the hospital has about 1008 beds and employs a large infection control department, which not only is involved with the main campus but also coordinates with all regional facilities. The mission of the infection control program is to “reduce the risk and incidence of health care acquired infections.” They also note that “infection prevention and control is an integrated and collaborative process throughout the entire organization.” The organization of the infection control program at CCF-main campus can be summarized as follows:

The Department of Infection Control and Epidemiology is under the umbrella of two divisions: the Division of Nursing and the Division of Medicine. The Division of Nursing is responsible for leadership, fiscal support, and administrative services. The Division of Medicine also shares responsibility with leadership and provides both technical and clinical direction. This department also has support and collaboration with other departments in CCF like Patient Support, Environmental Health and Safety, Center for Corporate Health, Occupational Health, Division of Laboratory Medicine, and Office of Quality Management.

 

ICP

Members of the Department of Infection Control and Epidemiology include four full-time and two part-time nurse epidemiologists who act as ICPs for the program. These are individuals who have training as a registered nurse and are certified by the Certification Board of Infection Control and Epidemiology. Each of these ICPs is responsible for different departments and nursing units within CCF depending on their areas of interest and expertise.

 

Infection Control Committee

The Infection Control Committee at CCF is chaired by the Hospital Epidemiologist and comprises of a multidisciplinary group of individuals that oversee the infection prevention and control programs. This committee is responsible for evaluating infection prevention measures, oversee changes in programs, law, and regulations, and review new guidelines and surveillance. The ICC reports directly to the Medical Staff Committee in CCF and frequently addresses administration concerns during ICC meetings. The ICC meets with planned agenda three times a year. Their meeting minutes are made available to relevant department and professional leaders.

 

The members of the ICC at CCF:

1. The Hospital Epidemiologist (Chair)

2. Associate Hospital Epidemiologist(s)

3. Clinical Department Representatives

a. Medicine

b. Surgery

c. Anesthesia

d. Laboratory Medicine (Microbiology)

e. Occupational Health

f. Pediatrics

g. Infectious Disease

h. House staff

4. Infection Control Practitioners

5. Nursing Quality Management - ad hoc

6. Nursing Administration - ad hoc

7. Intensive Care

8. Administration

9. Ad hoc Departments (Central Service, Environmental Services, Textile Services, Nutrition Services, Facilities Engineering, Pharmacy, Environmental Health and Safety, Materials Management, Operating Room, and Regional Medical Practice; to attend meetings when necessary and/or serve as consultants).

 

A smaller, more focused Executive Committee of the Infection Control Committee meets weekly to discuss day to day changes and concerns and to institute changes in outbreak management and infection control. Any major decisions or changes by the executive committee are brought forth to the complete ICC for consideration.

 

The Executive Committee membership includes:

1. Chairman of Infection Control Committee (Hospital Epidemiologist)

2. Associate Hospital Epidemiologist(s)

3. Infection Control Practitioners

4. Nursing Administration

5. Invited guests ad hoc

 

Infection Control, Prevention, and Surveillance

The major infection control and prevention measures used by CCF can be defined by the following points:

1.      Hand hygiene

2.      Use of barriers for contact with body substances such as blood

3.      Extensive programs for specific infections – focusing on transmission and precautions based on the organism

4.      Equipment and Medical Device Safety

5.      Health Screening of Employees and Immunization of employees and volunteers

6.      Post-Infection and Infection counseling and prophylactic treatment of employees and volunteers

7.      Reduce risk of animal infections brought into the hospital. It should be noted that CCF is also a research institution with animal studies.

 

Surveillance is another important aspect of infection prevention and control at CCF. Overall, surveillance is an on-going process based on systematic observation and documentation of all incidences of hospital acquired infections. A majority of surveillance however is based on the targeted and priority-directed approaches. That is, there is continuous surveillance in specific infections in certain units and surveillance of procedures associated with significant morbidity and mortality.  The results from the surveillance is used both internally within departments to look for trends and affect change and all reportable disease are also reported to the Ohio Department of Health.

 

Outbreak Management

In the case of an outbreak the chain of action by CCF is:

            1. Confirm that an outbreak exists

2. Establish or verify diagnosis of reported cases; identify agent

3. Search for additional cases; collect critical data and specimens

4. Characterize the cases by person, place, and time

5. Formulate tentative hypothesis (make the best guess to explain the observations

6. Test hypothesis

7. Consider control measures alternative - institute most appropriate

8. Evaluate efficacy of control measures

9. Communicate findings to Infection Control Committee and submit report to office of Quality Management Ad hoc working groups will be formulated to respond to perceived outbreaks or problems. The hospital epidemiologist and infection control practitioners select ad hoc members based on the pathogens or problems identified or as need determines.

 

Finally, the department of infection control and epidemiology at CCF is also involved with special situations and programs not directly linked to a particular unit within the hospitals. This department also monitors the following:

1.      Continuous education of both new and current employees

2.      Construction activity

3.      Research in infection control

 

Conclusion

            Nosocomial infections continue to be a burden to the American healthcare system through increased risks to patients and employees.  These infections have tremendous health and financial costs with an estimated incidence of 2,000,000 infections per year, 20,000 deaths per year, and added costs of 2 billion per year.  Effective infection control programs are essential to controlling and preventing nosocomial infections.  These programs include a core of the infection control committee, infection control practitioner, and individual employee actions.  Thus, it is important that we seek to continually improve existing infection control policies and programs.

 

 

 

References:

  1. Bolyard, EA, Tablan, OC, Williams, WW, Pearson, ML, Shapiro, CN, and Deitchman, SD. The Hospital Infection Control Practices Advisory Committee: Guideline for infection control in healthcare personnel. 1998
  2. Coffin SE and Zaoutis TE. Infection Control, Hospital Epidemiology, and Patient Safety. Infect Dis Clin N Am 19 (2005) 647-665
  3. Department of Infection Control and Epidemiology at Cleveland Clinic Foundation: Mission Statement and Infection Control Program – available within the Cleveland Clinic Foundation Intranet or through the Department.
  4. Ducel, G., Fabry, J., and L. Nicolle, “Prevention of hospital acquired infections: A Practical Guide, 2nd Edition,” World Health Organization 2002.                              http://www.who.int/emc
  5. Gordis, Leon, “Epidemiology, Third Edition,” Elsevier Saunders 2004.
  6. http://www.cdc.gov/ncidod/
  7. http://www.cdc.gov/ncidod/dhqp/nnis_pubs.html
  8. http://www.cdc.gov/ncidod/EID/vol5no1/rubin.htm
  9. http://www.cdc.gov/ncidod/eid/vol7no2/wenzel.htm
  10. http://www.emedicine.com/ped/topic1619.htm
  11. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVentilatorAssociatedPneumoniaOwensboro.htm
  12. http://www.jointcommission.org/
  13. Personal Correspondence with ICP at the Cleveland Clinic Foundation
  14. Wenzel, RP. Prevention and Control of Nosocomial Infections. 3rd Ed. Williams and Wilkins, 1997.

 

Additional Sources:

www.cdc.gov

www.ihi.org

www.jointcommission.org

www.who.int

 



[1] Ducel, G., Fabry, J., and L. Nicolle, “Prevention of hospital acquired infections: A Practical Guide, 2nd Edition,” World Health Organization 2002.

[2] Ducel, 4

[3] Gordis, Leon, “Epidemiology, Third Edition,” Elsevier Saunders 2004.

[4] Ducel, 4

[5] Ducel, 2

[6] Ducel, 2-3

[7] Ducel, 3

[8] Ducel, 5

[9] Ducel, 5

[10]http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVentilatorAssociatedPneumoniaOwensboro.htm

[11] Ducel, 5

[12] Ducel, 6

[13] http://www.emedicine.com/ped/topic1619.htm

 

[14] Ducel, 6-7

[15] Ducel, 7

[16] Ducel, 7

[17] Ducel, 7

[18] Ducel, 57

[19] Ducel, 57

[20] Ducel, 58

[21] Ducel, 58-59

[22] Ducel, 59

[23] Ducel, 59-60

[24] http://www.cdc.gov/ncidod/eid/vol7no2/wenzel.htm

[25] http://www.emedicine.com/ped/topic1619.htm

[26] http://www.emedicine.com/ped/topic1619.htm

[27] http://www.cdc.gov/ncidod/EID/vol5no1/rubin.htm

 

[28] Ducel, 4

[29] www.Jointcommission.org

[30] Wenzel, 57-58

[31] www.cdc.gov/ncidod

[32] Wenzel, 33-40

[33] Wenzel, 33-40

[34] Wenzel, 33-40

[35] Wenzel, 33-40

[36] www.cdc.gov/ncidod/dhqp/nnis_pubs.html

[37] Wenzel, 57-58

[38] Wenzel, 33-40

[39] Dept. of Infection Control and Epidemiology of CCF

[40] Wenzel, 33-40

[41] Wenzel, 57-67

[42] Wenzel, 57-67

[43] Wenzel, 57-67

[44] Bolyard

[45] Wenzel, 57-67

[46] Wenzel, 57-67

[47] Wenzel, 57-67

[48] Wenzel, 57-67

[49] Wenzel, 57-67

[50] www.jointcommission.org

[51] Ducel, 30-31

[52] Ducel, 30-31

[53] Ducel, 30-31

[54] Ducel, 32

[55] Ducel, 32

[56] Ducel, 32

[57] Ducel, 33

[58] Ducel, 33

[59] Ducel, 33

[60] Ducel, 33-34

[61] Ducel, 33-34

[62] Ducel, 33-34

[63] Wenzel, 75

[64] Coffin, et al.

[65] Wenzel, 127-153

[66] Wenzel, 127-153

[67] Wenzel, 127-153

[68] Wenzel, 127-153

[69] Wenzel, 127-153

[70] Wenzel, 127-153

[71] Personal Correspondence with CCF ICP

[72] Dept. of Infection Control and Epidemiology of CCF