Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee

НазваниеJane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee
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Part II:

Fundamental elements needed to prevent transmission of infectious agents in healthcare settings

II.A. Healthcare system components that influence the effectiveness of precautions to prevent transmission

II.A.1. Administrative measures Healthcare organizations can demonstrate a commitment to preventing transmission of infectious agents by incorporating infection control into the objectives of the organization’s patient and occupational safety programs 543-547. An infrastructure to guide, support, and monitor adherence to Standard and Transmission-Based Precautions 434, 548, 549 will facilitate fulfillment of the organization’s mission and achievement of the Joint Commission on Accreditation of Healthcare Organization’s patient safety goal to decrease HAIs 550. Policies and procedures that explain how Standard and Transmission-Based Precautions are applied, including systems used to identify and communicate information about patients with potentially transmissible infectious agents, are essential to ensure the success of these measures and may vary according to the characteristics of the organization.

A key administrative measure is provision of fiscal and human resources for maintaining infection control and occupational health programs that are responsive to emerging needs. Specific components include bedside nurse 551 and infection prevention and control professional (ICP) staffing levels 552, inclusion of ICPs in facility construction and design decisions 11, clinical microbiology laboratory support 553, 554, adequate supplies and equipment including facility ventilation systems 11, adherence monitoring 555, assessment and correction of system failures that contribute to transmission 556, 557, and provision of feedback to healthcare personnel and senior administrators 434, 548, 549, 558. The positive influence of institutional leadership has been demonstrated repeatedly in studies of HCW adherence to recommended hand hygiene practices 176, 177, 434, 548, 549, 559-564. Healthcare administrator involvement in infection control processes can improve administrators’ awareness of the rationale and resource requirements for following recommended infection control practices.

Several administrative factors may affect the transmission of infectious agents in healthcare settings: institutional culture, individual worker behavior, and the work environment. Each of these areas is suitable for performance improvement monitoring and incorporation into the organization’s patient safety goals 543, 544,

546, 565


II.A.1.a.Scope of work and staffing needs for infection control professionals

The effectiveness of infection surveillance and control programs in preventing nosocomial infections in United States hospitals was assessed by the CDC through the Study on the Efficacy of Nosocomial Infection Control (SENIC Project) conducted 1970-76 566. In a representative sample of US general hospitals, those with a trained infection control physician or microbiologist involved in an infection control program, and at least one infection control nurse per 250 beds, were associated with a 32% lower rate of four infections studied (CVC-associated bloodstream infections, ventilator-associated pneumonias, catheter-related urinary tract infections, and surgical site infections).

Since that landmark study was published, responsibilities of ICPs have expanded commensurate with the growing complexity of the healthcare system, the patient populations served, and the increasing numbers of medical procedures and devices used in all types of healthcare settings. The scope of work of ICPs was first assessed in 1982 567-569 by the Certification Board of Infection Control (CBIC), and has been re-assessed every five years since that time 558, 570-572. The findings of these task analyses have been used to develop and update the Infection Control Certification Examination, offered for the first time in 1983. With each survey, it is apparent that the role of the ICP is growing in complexity and scope, beyond traditional infection control activities in acute care hospitals. Activities currently assigned to ICPs in response to emerging challenges include: 1) surveillance and infection prevention at facilities other than acute care hospitals e.g., ambulatory clinics, day surgery centers, long term care facilities, rehabilitation centers, home care; 2) oversight of employee health services related to infection prevention, e.g. assessment of risk and administration of recommended treatment following exposure to infectious agents, tuberculosis screening, influenza vaccination, respiratory protection fit testing, and administration of other vaccines as indicated, such as smallpox vaccine in 2003; 3) preparedness planning for annual influenza outbreaks, pandemic influenza, SARS, bioweapons attacks; 4) adherence monitoring for selected infection control practices; 5) oversight of risk assessment and implementation of prevention measures associated with construction and renovation; 6) prevention of transmission of MDROs; 7) evaluation of new medical products that could be associated with increased infection risk. e.g.,intravenous infusion materials; 9) communication with the public, facility staff, and state and local health departments concerning infection control-related issues; and 10) participation in local and multi-center research projects 434, 549, 552, 558, 573, 574.

None of the CBIC job analyses addressed specific staffing requirements for the identified tasks, although the surveys did include information about hours worked; the 2001 survey included the number of ICPs assigned to the responding facilities 558 . There is agreement in the literature that 1 ICP per 250 acute care beds is no longer adequate to meet current infection control needs; a Delphi project that assessed staffing needs of infection control programs in the 21st century concluded that a ratio of 0.8 to 1.0 ICP per 100 occupied acute care beds is an appropriate level of staffing 552. A survey of participants in the National Nosocomial Infections Surveillance (NNIS) system found the average daily census per ICP was 115 316. Results of other studies have been similar: 3 per 500 beds for large acute care hospitals, 1 per 150-250 beds in long term care facilities, and 1.56 per 250 in small rural hospitals 573, 575. The foregoing demonstrates that infection control staffing can no longer be based on patient census alone, but rather must be determined by the scope of the program, characteristics of the patient population, complexity of the healthcare system, tools available to assist personnel to perform essential tasks (e.g., electronic tracking and laboratory support for surveillance), and unique or urgent needs of the institution and community 552. Furthermore, appropriate training is required to optimize the quality of work performed 558, 572, 576.

II.A.1.a.i. Infection Control Nurse Liaison Designating a bedside nurse on a patient care unit as an infection control liaison or “link nurse” is reported to be an effective adjunct to enhance infection control at the unit level 577-582. Such individuals receive training in basic infection control and have frequent communication with the ICPs, but maintain their primary role as bedside caregiver on their units. The infection control nurse liaison increases the awareness of infection control at the unit level. He or she is especially effective in implementation of new policies or control interventions because of the rapport with individuals on the unit, an understanding of unit-specific challenges, and ability to promote strategies that are most likely to be successful in that unit. This position is an adjunct to, not a replacement for, fully trained ICPs. Furthermore, the infection control liaison nurses should not be counted when considering ICP staffing.

II.A.1.b. Bedside nurse staffing There is increasing evidence that the level of bedside nurse-staffing influences the quality of patient care 583, 584. If there are adequate nursing staff, it is more likely that infection control practices, including hand hygiene and Standard and Transmission-Based Precautions, will be given appropriate attention and applied correctly and consistently 552. A national multicenter study reported strong and consistent inverse relationships between nurse staffing and five adverse outcomes in medical patients, two of which were HAIs: urinary tract infections and pneumonia 583. The association of nursing staff shortages with increased rates of HAIs has been demonstrated in several outbreaks in hospitals and long term care settings, and with increased transmission of hepatitis C virus in dialysis units 22, 418, 551, 585-597. In most cases, when staffing improved as part of a comprehensive control intervention, the outbreak ended or the HAI rate declined. In two studies 590, 596, the composition of the nursing staff (“pool” or “float” vs. regular staff nurses) influenced the rate of primary bloodstream infections, with an increased infection rate occurring when the proportion of regular nurses decreased and pool nurses increased.

II.A.1.c. Clinical microbiology laboratory support The critical role of the clinical microbiology laboratory in infection control and healthcare epidemiology is described well 553, 554, 598-600 and is supported by the Infectious Disease Society of America policy statement on consolidation of clinical microbiology laboratories published in 2001 553. The clinical microbiology laboratory contributes to preventing transmission of infectious diseases in healthcare settings by promptly detecting and reporting epidemiologically important organisms, identifying emerging patterns of antimicrobial resistance, and assisting in assessment of the effectiveness of recommended precautions to limit transmission during outbreaks

598. Outbreaks of infections may be recognized first by laboratorians 162. Healthcare organizations need to ensure the availability of the recommended scope and quality of laboratory services, a sufficient number of appropriately trained laboratory staff members, and systems to promptly communicate epidemiologically important results to those who will take action (e.g., providers of clinical care, infection control staff, healthcare epidemiologists, and infectious disease consultants) 601. As concerns about emerging pathogens and bioterrorism grow, the role of the clinical microbiology laboratory takes on even greater importance. For healthcare organizations that outsource microbiology laboratory services (e.g., ambulatory care, home care, LTCFs, smaller acute care hospitals), it is important to specify by contract the types of services (e.g., periodic institution-specific aggregate susceptibility reports) required to support infection control.

Several key functions of the clinical microbiology laboratory are relevant to this guideline:

  1. Antimicrobial susceptibility by testing and interpretation in accordance with current guidelines developed by the National Committee for Clinical Laboratory Standards (NCCLS), known as the Clinical and Laboratory Standards Institute (CLSI) since 2005 602, for the detection of emerging resistance patterns 603, 604, and for the preparation, analysis, and distribution of periodic cumulative antimicrobial susceptibility summary reports 605-607. While not required, clinical laboratories ideally should have access to rapid genotypic identification of bacteria and their antibiotic resistance genes 608.

  2. Performance of surveillance cultures when appropriate (including retention of isolates for analysis) to assess patterns of infection transmission and effectiveness of infection control interventions at the facility or organization. Microbiologists assist in decisions concerning the indications for initiating and discontinuing active surveillance programs and optimize the use of laboratory resources.

  3. Molecular typing, on-site or outsourced, in order to investigate and control healthcare-associated outbreaks 609.

  4. Application of rapid diagnostic tests to support clinical decisions involving patient treatment, room selection, and implementation of control measures including barrier precautions and use of vaccine or chemoprophylaxis agents (e.g., influenza 610-612, B. pertussis 613, RSV 614, 615, and enteroviruses 616). The microbiologist provides guidance to limit rapid testing to clinical situations in which rapid results influence patient

management decisions, as well as providing oversight of point-of-care

testing performed by non-laboratory healthcare workers 617.

  1. Detection and rapid reporting of epidemiologically important organisms, including those that are reportable to public health agencies.

  2. Implementation of a quality control program that ensures testing services are appropriate for the population served, and stringently evaluated for sensitivity, specificity, applicability, and feasibility.

  3. Participation in a multidisciplinary team to develop and maintain an effective institutional program for the judicious use of antimicrobial agents

618, 619


II.A.2. Institutional safety culture and organizational characteristics Safety culture (or safety climate) refers to a work environment where a shared commitment to safety on the part of management and the workforce is understood and followed 557, 620, 621. The authors of the Institute of Medicine Report, To Err is Human 543, acknowledge that causes of medical error are multifaceted but emphasize repeatedly the pivotal role of system failures and the benefits of a safety culture. A safety culture is created through 1) the actions management takes to improve patient and worker safety; 2) worker participation in safety planning; 3) the availability of appropriate protective equipment; 4) influence of group norms regarding acceptable safety practices; and 5) the organization’s socialization process for new personnel. Safety and patient outcomes can be enhanced by improving or creating organizational characteristics within patient care units as demonstrated by studies of surgical ICUs 622, 623. Each of these factors has a direct bearing on adherence to transmission prevention recommendations 257. Measurement of an institutional culture of safety is useful for designing improvements in healthcare 624, 625. Several hospital-based studies have linked measures of safety culture with both employee adherence to safe practices and reduced exposures to blood and body fluids 626-632. One study of hand hygiene practices concluded that improved adherence requires integration of infection control into the organization’s safety culture 561. Several hospitals that are part of the Veterans Administration Healthcare System have taken specific steps toward improving the safety culture, including error reporting mechanisms, performing root cause analysis on problems identified, providing safety incentives, and employee education. 633-635 .

II.A.3. Adherence of healthcare personnel to recommended guidelines

Adherence to recommended infection control practices decreases transmission of infectious agents in healthcare settings 116, 562, 636-640. However, several observational studies have shown limited adherence to recommended practices by healthcare personnel 559, 640-657. Observed adherence to universal precautions ranged from 43% to 89% 641, 642, 649, 651, 652. However, the degree of adherence depended frequently on the practice that was assessed and, for glove use, the circumstance in which they were used. Appropriate glove use has ranged from a low of 15% 645 to a high of 82% 650 . However, 92% and 98% adherence with glove use have been reported during arterial blood gas collection and resuscitation, respectively, procedures where there may be considerable blood contact 643, 656. Differences in observed adherence have been reported among occupational groups in the same healthcare facility 641 and between experienced and nonexperienced professionals 645. In surveys of healthcare personnel, self-reported adherence was generally higher than that reported in observational studies. Furthermore, where an observational component was included with a self-reported survey, self-perceived adherence was often greater than observed adherence 657. Among nurses and physicians, increasing years of experience is a negative predictor of adherence 645, 651. Education to improve adherence is the primary intervention that has been studied. While positive changes in knowledge and attitude have been demonstrated, 640, 658, there often has been limited or no accompanying change in behavior 642, 644. Self-reported adherence is higher in groups that have received an educational intervention 630, 659. Educational interventions that incorporated videotaping and performance feedback were successful in improving adherence during the period of study; the long-term effect of these interventions is not known 654.The use of videotape also served to identify system problems (e.g., communication and access to personal protective equipment) that otherwise may not have been recognized. Use of engineering controls and facility design concepts for improving adherence is gaining interest. While introduction of automated sinks had a negative impact on consistent adherence to hand washing 660, use of electronic monitoring and voice prompts to remind healthcare workers to perform hand hygiene, and improving accessibility to hand hygiene products, increased adherence and contributed to a decrease in HAIs in one study 661. More information is needed regarding how technology might improve adherence. Improving adherence to infection control practices requires a multifaceted approach that incorporates continuous assessment of both the individual and the work environment 559, 561. Using several behavioral theories, Kretzer and Larson concluded that a single intervention (e.g., a handwashing campaign or putting up new posters about transmission precautions) would likely be ineffective in improving healthcare personnel adherence 662. Improvement requires that the organizational leadership make prevention an institutional priority and integrate infection control practices into the organization’s safety culture 561. A recent review of the literature concluded that variations in organizational factors (e.g., safety climate, policies and procedures, education and training) and individual factors (e.g., knowledge, perceptions of risk, past experience) were determinants of adherence to infection control guidelines for protection against SARS and other respiratory pathogens 257.
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