oversight

Basic Elements of an Infection Control Program

Published by the Government Accountability Office on 1990-01-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

.’Preface



                The Centers for Disease Control estimates that
                about 5 percent of all patients who enter hospitals
                contract at least one infection during their stay.
                Hospital-based infections result in increased patient
                suffering and sometimes death; longer hospital
                stays; and increased health care costs. Effective
                infection control programs can reduce the number
                of nosocomial infections, and researchers have esti-
                mated that such programs can more than pay for
                themselves by reducing patients’ lengths of stay
                and the related costs of treating infections.
                We have prepared this listing of elements that
                experts consider necessary for effective hospital-
                baaed infection control programs in order to share it
                with infection control practitioners and program
                directors and other interested parties. We developed
                the listing to assessthe content of infection control
                programs in the Departments of Veterans Affairs
                (VA) and Defense hospitals and to compare such
                programs with those in nonfederal hospitals. We
                found that federal and nonfederal hospitals were
                similar in their use of the elements and many hospi-
                tals use a significant number of them. For example,
                our survey of 443 nonfederal hospitals showed that
                42 of the 56 elements were being used by over 70
                percent of the hospitals when such use was
                appropriate. l

                The 56 elements reflect current thinking on basic
                infection control program activities. We developed
                these elements by first consulting with officials of
                the organizations and the individual that follow:
            l   American Hospital Association.
            l   Association for Practitioners in Infection Control.
            l   Centers for Disease Control (cnc).

                ‘For more details on our comparison of VA and nonfederal hospi-
                tals’ infection control programs see our report, Infection Control:
                VA Programs Are Comparable to Nonfederal Programs but Can Be
                Enhanced (GAO/HRD-90-27).Our report on the comparison of
                Department of Defense and nonfederal hospitals will be published
                later this year.


                Page 1                                        GAO/I.lRD-99-25
    Preface




l   Joint Commission on Accreditation of Healthcare
    Organizations.
l   The Society of Hospital Epidemiologists of America.
l   Robert W. Haley, M .D., who directed cnc’s Study on
    the Efficacy of Nosocomial Infection Control
    (SENIC).?

    We discussed the activities these officials thought
    were necessary for an effective infection control
    program and worked with cnc officials to compile a
    comprehensive list of elements. The list was sent to
    the above organizations (except cnc) as well as the
    following organizations:
l   American Public Health Association.
l   The Association of Operating Room Nurses, Inc.
l   Association of State and Territorial Health Officials.
l   Surgical Infection Society.
    We asked each to indicate which elements could be
    considered m inimum requirements for an effective
    infection control program. Prom their responses,we
    developed a list of the elements that six or more
    agreed were m inimum requirements and, subse-
    quently, discussed these with cnc infection control
    experts. Using existing Joint Commission standards,
    published studies demonstrating the effectiveness
    of an element, and CDC’judgment
                               S         as to whether the
    element would be widely supported by infection
    control experts, we arrived at a final list of 56 ele-
    ments. These elements focus on the surveillance
    activities of an infection control program.

    We believe that these elements should be useful to
    both practitioners and hospitals in starting or eval-
    uating infection control programs. However, the ele-
    ments indicate only whether an infection control
    program involves certain activities and should not
    be used by themselves to assessthe program’s
    effectiveness. Other important determinants of a

    “In thii study, CL% evaluated the impact of surveillance and con-
    trol activities on nosocomial infections in a sample of hospitals.


    Page 2                                        GAO/HRD-99-25
        .
    >
,
            Preface




            program’s effectiveness include hospital and pro-
            gram priorities, availability of data to identify prob-
            lems, and, most significantly, how well infection
            control activities are carried out by hospital staff.
            The field of infection control is a dynamic one. Bet-
            ter ways to ascertain the risk of nosocomial infec-
            tions and reduce infection rates continue to be
            found. Our hope is that these basic elements will be
            expanded and modified to reflect further develop-
            ments in infection control program knowledge and
            practices.


              Asuc.sLk
            Lcud  \ OTti
                 -e
            Lawrence H. Thompson
            Assistant Comptroller General for
              Human Resources Programs




            Page 3                               GAO/HRD-90-25
Basic Elements of an Infection
Control Program


Applicability of   The basic elements cited in this pamphlet are appli-
                   cable only to acute-care hospitals having 50 or more
the Elements       beds. Infection control programs for hospitals with
                   less than 50 beds should entail many of the same
                   types of activities but could be less structured than
                   programs for larger facilities. Also, infection control
                   programs in extended care facilities may be some-
                   what different because the infection risks, availa-
                   bility of diagnostic tests, and organizational
                   structure may not be the same as in acute-care
                   hospitals.


Use of the Basic   The basic elements are divided into five groups:
                   general program elements, bloodstream infections,
Elements           pneumonia, surgical wound infections, and urinary
                   tract infections. The general group includes 14 ele-
                   ments that apply to all hospitals and address pro-
                   gram structure, applicable surveillance activities,
                   and control activities. The remaining four groups of
                   elements are organized by the four major sites of
                   infection and address surveillance activities (identi-
                   fication, analysis, and reporting) specific to each
                   site.

                   The elements allow for both total and targeted sur-
                   veillance. A program performing total surveillance
                   monitors all four major sites of infection in every
                   hospital patient on either a periodic or continuous
                   basis. A program that targets surveillance identifies
                   the areas of highest infection risk or concern and
                   focuses its attention on such areas; for example,
                   patients in the intensive care unit or all bloodstream
                   infections. The specific elements applicable to an
                   infection control program depend on whether the
                   program uses total or targeted surveillance:
                   Total surveillance-all five groups of elements
                   would be used, however, a few individual elements
                   within the groups may not be applicable (see the
                   basic elements).




                   Page 4                                GAO/DRD-90-26
Basic Elements of an
Infection Control Program




Targeted surveillance-the general elements would
be used, and, depending on which site(s) of infec-
tions are being targeted in the high risk groups,
other appropriate groups of elements would be used
(i.e., bloodstream, pneumonia, surgical wound, or
urinary tract).

Although the basic elements place emphasis on sur-
veillance activities, an infection control program
cannot be effective without control activities. We
included in our list only the broad categories of con-
trol functions because control activities, unlike sur-
veillance activities, are performed not only by the
infection control staff but by other hospital person-
nel. cnc has published detailed recommendations on
procedures to be followed by providers to prevent
infections. Further, control activities that (1) are
carried out by the program and (2) are beneficial to
all hospitals are difficult to specify becausethe
appropriate control activities depend heavily on the
surveillance findings and the circumstances within
the individual hospital. For example, if a program
finds it has a high rate of bloodstream infections
related to intravenous catheters, the appropriate
control activity could be to revise the hospital pol-
icy on changing intravenous catheters or provide in-
service training for residents or nurses responsible
for inserting or changing the catheters.

The list of elements that follows is not all inclusive;
the elements listed form a basic rather than an opti-
mal program. Therefore, the elements should be
used in conjunction with other standards, such as
the Joint Commission’s accreditation standards and
CDC’Sguidelines.




Page 6                                 GAO/ERD-90-26
General Elements
(These apply to all hospitals)


Structure
Gl.
The hospital has at least a part-time infection control
practitioner.
G2.
The hospital has a physician who supervises or consults in
the infection control program and has taken at least one
training course in hospital infection control.
G3. -
The hospital has a multidisciplinary infection control
committee.
G4.
Permanent membership on the commrttee includes
representation from the following:
*hospital administration,
*microbiology   laboratory (if one exists),

*medical staff, and
*nursing service.
G5.
The committee meets at least everv 2 months
Surveillance Activities
G6.
The infection control program performs surveillance for at
least one of the four major infection sites (bloodstream,
pneumonia, surgical wound, and urinary tract).
G7.
The hospital’s infection control program has written
standardized criteria (definitions) for nosocomial infections at
specific sites.
GE.
The infection control program has a system to detect and
control outbreaks of infections.
Control Activities
G9.
The hospital’s infection control program assists in developing
and revising hospital departments’ policies and procedures
as they relate to infection control issues.
GIO.
The hospital’s infection control program assists in developing
a system for reporting infections or infection exposures of
employees.         _
                                                                          (continued)

                                    Page 6                         GAO/EItD-90-25
        *
    k
.
                                     General Elements




    Structure
    Gil.
    The hospital’s infection control program assists in identifying
    and developing infection control topics for orientation
    classes.
    G12.
    The hospital’s infection control program assists in identifying
    and developing infection control topics for in-service training.
    G13.
    The hospital’s infection control program monitors or assists in
    monitoring the hospital staff’s compliance with specific
    patient care practices, such as aseptic techniques during
    intravenous catheter insertion and maintenance of insertion
    sites.
    G14.
    Infection control practitioners and registered nurses on
    hospitals units have written authority to implement isolation
    procedures in an emeraencv without a chvsician’s order.




                                     Page 7                            GAO/m-90-25
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                                                                                            i
                                                                                                    l



Blood&rem Infections



                                                                      Applicability to
                                                                     surveillance type
 identification                                                         Total          Target
 Bl.
 A hospital’s infection control program uses at least one of the            X                   X
 following case-finding approaches to identify bloodstream
 infections either in all patients or in a subset of patients:
?
 l Review    results of blood cultures in all patients in target
   population.
l    Review all patients’ charts in target population.

l    Review all patients’ fever charts in target population.
B2.                                                                         X                   X
Duriig the surveillance period, a hospital’s infection control
program performs an acceptable case-finding approach
(previous criterion) on an average of every 3 daysa
83.                                                                         X                   X
In their case-confirmation effort, infection control staff perform
at least one of the following activities if they do not review all
patients’ charts in target population as a case-finding activity:
l    Review results of blood cultures in patients in target
     population, identified through case finding (if they do not
     review results of blood cultures in all patients in target
     population as a case-finding activity).

l     Review patients’ charts in target population identified
      through case finding.
    Analysisb
    B4.                                                                     X                   X
    The infection control program has developed initial baseline
    rates for nosocomial bloodstream infections within the
    hosdtal.
    B5.                                                                     X                   X
    Infection control staff analyze nosocomial bloodstream
    infection data bv bathoaen.
    B6.                                                                                         X
    Infection control staff analyze data on nosocomial
    bloodstream infections by whether or not patient had
    peripheral and/or central intravenous (IV) cannulation.
    87.                                                                     X                   X
    Infection control staff analyze nosocomial bloodstream
    infection data bv ward.
                                                                                  (continued)



                                       Page 8                              GAO/ERD-90-26
.
                                      Bloodstream     Infections




                                                                                    Applicability to
                                                                                   surveillance type
    Repotting                                                                         Total          Target
    B8.                                                                                     X                  X
    Infection control staff report summarized/    analyzed data on
    nosocomial bloodstream      infections to the infection control
    committee.
    B9.                                                                                                        X
    Infection control staff report summarized/    analyzed data on
    nosocomial bloodstream      infections to the supervisor of the IV
    therapy team, if one exists.
    BlO.                                                                                    X                  X
    Infection control staff report summarized/    analyzed    data to
    the ward supervisors or head nurses.
                                       almportant infection control problems may require case finding
                                       more frequently than every 3 days.

                                       bThe proper analysis of infection data requires calculation of infec-
                                       tion rates in specific patient risk groups, as well as frequency distri-
                                       butrons and line listings of the infections. If infection rates are to be
                                       useful for estimating infection risks in patient groups, appropriate
                                       data should be collected; for example, if bloodstream infections
                                       caused by intravenous catheters are being analyzed, then both the
                                       number of patients with Intravenous catheters and the number of
                                       those patients who develop bloodstream infections are needed.




                                       Page 9                                             GAO/ERD-90-25
Pneumonia



                                                                          Applicability to
                                                                         surveillance type
Identification                                                              Total          Target
Pl .
A hospital’s infection control program uses at least one of the                 X               X
following case-finding approaches to identify pneumonia
either in all patients or in a subset of patients:
l       Review all patients’ Kardexes in target population.

l       Ask nurses about signs or symptoms of a respiratory
        infection in all patients in target population.

l    Review all patients’ charts in target population.
    P2.                                                                         X               X
    During the surveillance period, a hospital’s infection control
    program performs an acceptable case-finding approach
    (previous criterion) on an average of every 3 days.a
    P3.                                                                         X               X
    In their case-confirmation effort, infection control staff perform
    at least one of the following activities if they do not review all
    patients’ charts in target population as a case-finding activity:

. Review lab and X-ray results for evidence of pneumonia in
  patients in target population, identified through case finding
  (if they do not review lab and X-ray results in all patients in
  target population as a case-finding activity).
    l Review patients’ charts in target population identified
      through’case finding.          -
    Analvsisb
    P4.                                                                         X               X
    The infection control program has developed initial baseline
    rates for nosocomial pneumonia within the hosprtal.
    P5.                                                                         X               X
    Infection control staff analyze data on nosocomial pneumonia
    by pathogen.
    P6.                                                                                         X
    Infection control staff analyze data on nosocomial pneumonia
    by whether or not patient was on a ventilator, if target
    population includes ventilator patients.
    P7.                                                                         X               X
    Infection control staff analyze data on nosocomial pneumonia
    bv ward.




                                        Page 10                               GAO/EItD-99-25
                                  Pneumonia




                                                                               Applicability     to
                                                                              surveillance     type
                                                                                 Total              Target
P8.                                                                                    X                  X
Infection control staff analyze data on nosocomial pneumonia
by whether or not patient had surgery, if target population
includes surgical patients.
Reporting
P9.                                                                                    X                  X
Infection control staff report summarized/ analyzed data on
nosocomial pneumonia to the infection control committee.
PIO.                                                                                                      X
If target population includes ventilator patients, infectron
control staff report summarized/analyzed     data on nosocomial
pneumonra to the respiratory therapy department,       if one
exists.
Pll.                                                                                   X                     X
Infection control staff report summarized/ analyzed data on
nosocomial pneumonia to the ward supervisors or head
nurses.
                                  almportant infection control problems may require case finding
                                  more frequently than every 3 days.

                                  bThe proper analysis of infection data requires calculation of infec-
                                  tion rates in specific patient risk groups, as well as frequency distn-
                                  butions and line listings of the infections. If Infection rates are to be
                                  useful for estimating infection risks in patient groups, appropriate
                                  data should be collected; for example, if bloodstream infections
                                  caused by intravenous catheters are being analyzed, then both the
                                  number of patients with intravenous catheters and the number of
                                  those patients who develop bloodstream infections are needed.




                                  Page 11                                            GAO/JBD-99-25
Surgical Wound Infections



                                                                          Applicability to
                                                                         surveillance type
Identification                                                              Total          Target
Sl.
A hospital’s infection control program uses at least one of the                 X               X
following case-finding approaches to identify surgical wound
infections either in all surgical patients or in a subset of
surgical patients:

l       Review results of gram stains and cultures of wounds in all
        patients in target population, and ask nurses about signs or
        symptoms of surgical wound infections in all patients in
        target population.

    l   Review all surgical patients’ Kardexes in target population.
    l   Review all surgical patients’ charts in target population.
    s2.                                                                         X                   X
    During the surveillance period, a hospital’s infection control
    program conducts case finding using an acceptable
    approach (previous criterion) on an average of every 3 days.a
    s3.                                                                         X                   X
    In their case-confirmation effort, infection control staff perform
    at least one of the following activities if they do not review all
    surgical patients’ charts in target population as a case-finding
    activity:
    l   Review results of gram stains and wound cultures for
        patients in target population identified through case finding
        (if they do not review gram stains and wound cultures for all
        patients in target population as a case-finding activity).

    l   Review surgical patients’ charts in target population
        identified through case finding.
    lAsk nurses about signs or symptoms of surgical wound
      infections in patients in target population identified through
     case finding (if they do not ask nurses about signs or
     symptoms of surgical wound infections in all patients in
     target population as a case-finding activity).
    Analvsisb
    s4.                                                                         X                   X
    The infection control program has developed initial baseline
    rates for suraical wound infections in the hosoital.
    s5.                                                                          x                  X
    Infection control staff analyze surgical wound infection data
    by surgeon.
                                                                                      (continued)

                                         Page 12                                GAO/HRD-90-25
        t
    F
.
                                      Surgkal   Wound Infections




                                                                                   Applicability to
                                                                                  surveillance type
                                                                                     Total          Target
    S6.                                                                                                  X
    Infection control staff analyze surgical infection data by type
    of wound classification (e.g., clean, clean-contaminated,
    contaminated, and dirty).
    s7.                                                                                    X                  X
    Infection control staff analyze surgical wound infection data
    by pathogen.
    S8.                                                                                    X                  X
    Infection control staff analyze surgical wound infection data
    bv ward.
    Reporting
    s9.                                                                                    X                  X
    Infection control staff report summarized/ analyzed data on
    surqical wound infections to the infection control committee.
    SlO.                                                                                   X                  X
    Infection control staff report summarized/ analyzed data on
    surgical wound infections to the surgical complications
    committee, if one exists.
    Sll.                                                                                   X                  X
    Infection control staff report summarized/ analyzed data on
    surgical wound infections to the chief of the surgical service.
    s12.                                                                                   X                  X
    Infection control staff report summarized/ analyzed data on
    surgical wound infections to the operating room supervisor.
    s13.                                                                                   X                  X
    Practicina suraeons receive suraeon-specific infection rates.
                                      ?mportant infection control problems may require case finding
                                      more frequently than every 3 days
                                      bThe proper analysis of infectron data requires calculation of infec-
                                      tion rates in specific patient risk groups, as well as frequency distri-
                                      butions and line listings of the infections. If infection rates are to be
                                      useful for estimating infection risks in patient groups, appropriate
                                      data should be collected; for example, if bloodstream infections
                                      caused by intravenous catheters are being analyzed, then both the
                                      number of patients with intravenous catheters and the number of
                                      those patients who develop bloodstream infections are needed.




                                     Page 13                                             GAO/EtRD-90-25
Urinary Tract Infections



                                                                          Applicability to
                                                                         surveillance type
 Identification                                                             Total          Target
 Ul.
A hospital’s infection control program uses at least one of the                 X               X
following case-finding approaches to identify urinary tract
 infections either in all patients or in a subset of patients:
l Review all patients’ Kardexes     in target population.

l    Review results of urine cultures in all patients In target
     population, and ask nurses about signs or symptoms of a
     urinary tract infection in all patients in target population.

l     Review all patients’ charts in target population.
    u2.                                                                         X               X
    During the surveillance period, a hospital’s infection control
    program performs an acceptable case-finding approach
    (previous criterion) on an average of every 3 days.a
    u3.                                                                         X               X
    In their case-confirmation effort, infection control staff perform
    at least one of the following activities if they do not review all
    patients’ charts in target population as a case-finding activity:
l    Review results of urine cultures in patients in target
     population, identified through case finding (if they do not
     review lab results of urine cultures in all patients in target
     population as a case-finding activity).

l Review patients’ charts in target population identified
  throuah case findina.
Analysisb
u4.                                                                             X               X
The infection control program has developed initial baseline
rates for nosocomial urinary tract infections within the
hospital.
u5.                                                                             X               X
Infection control staff analyze data on nosocomial urinary
tract infections by pathogen.
U6.                                                                             X               X
Infection control staff analyze data on nosocomial urinary
tract infections by ward.
Reoortina
U7.                                                                             X               X
Infection control staff report summarized/ analyzed data on
nosocomial urinary tract infections to the infection control
committee.


                                       Page 14                                 GAO/HRD-90-25
                                 Urinary   Tract Infections




                                                                             Applicability to
                                                                            surveillance type
                                                                               Total          Target
U8.                                                                                  X              X
Infection control staff report summanzed/ analyzed data on
nosocomial urinary tract infections to the ward supervisors or
head nurses.
                                 9mportant infection control problems may requrre case finding
                                 more frequently than every 3 days.
                                bThe proper analysis of infection data requires calculation of infec-
                                tion rates in specific patient risk groups, as well as frequency distri-
                                butions and line listings of the infections. If infection rates are to be
                                useful for estimating infection risks in patient groups, appropriate
                                data should be collected; for example, if bloodstream infections
                                caused by intravenous catheters are being analyzed, then both the
                                number of patients with intravenous catheters and the number of
                              ( those patients who develop bloodstream infections are needed.




                                Page 16                                            GAO/EKED-90-25
Acknowledgements


               We wish to thank the following organizations and
               individual for their counsel as we formulated and
               attempted to obtain consensus on the basic elements
               of an effective infection control program.

           l American Hospital Association.
           l American Public Health Association.
           l The Association of Operating Room Nurses, Inc.
           l Association for Practitioners in Infection Control.
           l Association of State and Territorial Health Officials.
           l Centers for Disease Control (cnc).
           . Joint Commission on Accreditation of Healthcare
             Organizations.
           l The Society of Hospital Epidemiologists of America.
           l Surgical Infection Society.
           . Robert W. Haley, M.D., who directed CDC’SStudy on
             the Efficacy of Nosocomial Infection Control
               (SENIC).’

               We particularly want to acknowledge James 0.
               Mason, M.D., Assistant Secretary for Health, who
               supported us in this effort, and the hospital infec-
               tion control experts within the Center for Infectious
               Diseases at cnc, who provided advice throughout
               the proje&. In addition, we would like to thank the
               infection control practitioners in the Department of
               Veterans Affairs and Department of Defense and
               the sample of nonfederal hospitals who responded
               to our questionnaire on their programs’ activities.
               We sincerely appreciate their efforts to complete
               the questionnaire and to give us response rates of
               100,97, and 85 percent, respectively.




               ’SENIC evaluated the impact of surveillance and control activities
               on nosocomial infections in a sample of hospitals.

               Page 16                                       GAO/HRD-90-25