oversight

Infection Control: VA Programs Are Comparable to Nonfederal Programs but Can Be Enhanced

Published by the Government Accountability Office on 1990-01-31.

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

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                                    INFECTION
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                I               '




                                    CONTROL
                                    VA Programs Are
                                    Comparable to
                                    Nonfederal I’rograrns
                                    but Can Be Enhanced
-     united
        State8                                                             “.4
                                                                             ,’‘,,::*i               vd
cA0   General Accountinyr Office
      Washington, D.C. 20548
                                                                                ‘p;   !


      Human Beeourcee Division

      B-232863

      January 31,199O
      The Honorable Frank H. Murkowski
      Ranking Minority Member
      Committee on Veterans’ Affairs
      United States Senate
      Dear Senator Murkowski:
      In responseto your request, this report discussesthe effectiveness of the Department of
      Veterans Affairs’, (VA'S) infection control programs and how the programs compare with
      those in nonfederal hospitals. To assessVA'S programs we developed basic elements of
      hospital infection control programs. Using these elements we found the content of VA medical
      centers’ and nonfederal hospitals’ programs to be similar. However, our visits to sevenVA
      medical centers indicated that many of the VA programs were understaffed and neededmore
      support from medical center management.Several recommendations are made to improve
      these conditions, all of which VA concurred with and indicated that action was being taken.

      Copies of this report are being sent to the Secretary of Veterans Affairs, appropriate
      congressionalcommittees, and other interested parties.
      This report was prepared under the direction of David P. Baine, Director, Federal Health
      Care Delivery Issues,who may be reached on (202) 276-6207.Other major contributors are
      listed in appendix VII.

      Sincerely yours,




      Lawrence H. Thompson
      Assistant Comptroller General
  !




Ekecutive Summary


Purpose          The Centers for DiseaseControl (CDC)estimates that some6 percent of
                 the patients who enter a hospital contract an infection during their stay,
                 With over 1.3 million inpatient admissions annually, some60,000 veter-
                 ans could contract infections each year while being treated in hospitals
                 operated by the Department of Veterans Affairs (VA). The incidence of
                 hospital-acquired infections can be reduced, however, if hospitals oper-
                 ate effective programs to control infections.
                 The Ranking Minority Member of the SenateVeterans’ Affairs Commit-
                 tee asked GAO to review and evaluate infection control programs at VA
                 medical centers. Specifically, he requested that GAO determine
             . whether infection control data are used to help prevent future
               infections,
             . whether VA medical centers have adequately staffed and organized their
               infection control programs, and
             l how VA'S infection control programs compare with those of nonfederal
               hospitals.

                 VA operates 169 medical centers throughout  the United States, VA
B$ckground       requires each center to have an infection control program to identify
                 infections and help prevent future ones.
                 GAO neededcriteria   outlining the basic elements of an effective infection
                 control program in order to assessthe programs VA operates at its medi-
                 cal centers. It found that the program guidance issued to the medical
                 centers by VA'S central office was too broad to serve this purpose. It also
                 found, however, that no other U.S. health care organization had up-to-
                 date and specific guidance. In order to undertake this review, therefore,
                 GAO worked with representatives of nine organizations and one other
                 individual with expertise in infection control to develop a list of 66 basic
                 elements of an effective program. The nine organizations included the
                 Centers for DiseaseControl (CDC), the Joint Commissionon Accredita-
                 tion of Healthcare Organizations, the Association for Practitioners in
                 Infection Control and the Society of Hospital Epidemiologists of
                 America. (Seeapp I.)
                 These elements, referred to in this report as GAO'S elements, are applica-
                 ble to infection control programs in any acute-carehospital with more
                 than 60 beds. (Seeapp 11.)




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                           GAO used these elements to  examine the content of VA'S infection control
                           programs. It collected information through visits to sevenmedical cen-
                           ters and a questionnaire sent to all VA medical centers and a sample of
                           667 nonfederal hospitals. GAO used the questionnaire responsesto com-
                           pare VA infection control programs with those in nonfederal hospitals,

                           Both VA and nonfederal infection control programs are using most of
                           GAO'S basic elements. Forty-four of the elements are widely used by VA
                           infection control programs and 42 of the sameelements are widely used
                           by nonfederal programs. In the VA medical centers GAO visited, the use of
                           the elements was due to the individual initiative of the infection control
                           practitioners. Most of GAO'S elements either are not included in VA guid-
                           ance or are stated in such a general manner that VA'S guidance is of little
                           use to VA practitioners. Becausethey had only limited guidance and
                           direction from VA'S central office, VA practitioners sought current infec-
                           tion control information and implemented many activities that went
                           beyond their guidance and met the basic elements.
                           Several infection control elements that GAO identified, however, should
                           be used by more practitioners in both the public and private sector.
                           These elements are generally more labor intensive than those that are
                           receiving widespread acceptance.

                           In addition, to be most effective, VA programs need managementatten-
                           tion VA infection control programs are generally understaffed, not coor-
                           dinated at the central office, and not adequately monitored by the
                           regional offices. At the central office, six different units issue infection
                           control guidance. There is no central focal point. At the sevenmedical
                           centers GAO visited, regional office oversight of infection control pro-
                           grams was limited.


i   Principal Findings

    VA Infection Control   VA'S overall  guidance on infection control programs was issued in 1978
    Guidance Needs to Be   and 1979, and has not been updated since. Of the 66 elements GAO
                           believes should be basic to any program, VA'S guidance specifies clearly
    Updated      r         only 16. Seventeenof the elements are not mentioned in VA'S guidance
                           and the other 23 are discussedin such vague terms that their inclusion
                           is of little use to practitioners. At five of the seven centers GAO reviewed,


                           Page 3                               GAO/HRD-99-27VA’sInfection Control Programs



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                          ExecutiveSummary




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                          the infection control practitioners took the initiative to take training,
                          contact others, or read literature concerning infection control programs.
                          As a result, they used activities in their programs that went beyond VA
                          guidance and adhered to most of GAO'S basic elements.(Seepp. M-19.)
                          Twelve of the elements identified by GAO are not being used as fre-
                          quently by the medical centers as the other 44. These elements either
                          are not included in VA'S guidance or are stated so vaguely that the guid-
                          ance is of little use to practitioners. They include: assuring that physi-
                          cian advisors have taken a course in hospital infection control programs,
                          increasing the frequency of activities to identify certain infections, rou-
                          tinely reporting surgical wound infection rates to practicing surgeons,
                          and reporting ward-specific infection data to ward supervisors. (Seepp.
                          19 to 26. )


V& Infection Control      In terms of the extent to which each are using the GAO elements, VA'S
PrQgramsComparable        infection control programs are comparable with those of nonfederal hos-
                          pitals. VA practitioners generally use 44 of the elements, while
W&h Those in Nonfederal   nonfederal practitioners use 42. With the exception of one area, the spe-
Hqspitals                 cific elements used are the sameand the utilization rates are similar.
                          The specific elements that are being used less in VA are also being used
                          less in nonfederal hospitals and, again, the utilization rates are similar,


Minagement Issues Must    VA'S guidance requires one full-time infection control practitioner for
Be’Resolved               every 200 to 260 occupied beds. Basedon this requirement, GAO'S ques-
                          tionnaire results indicated that 66 percent of VA'S infection control pro-
                          grams were understaffed in 1987. At three of the sevenmedical centers
                          GAO reviewed, lack of resourcesled to the practitioners’ not accomplish-
                          ing necessaryinfection control activities. (Seepp. 28 to 30.)
                          GAO found  that regional office monitoring was inadequate at four of the
                          sevenmedical centers it visited. The VA regional office inspection team
                          did not identify existing deficiencies, each of which was significant
                          enough to hamper the effectiveness of the centers’ infection control pro-
                          grams. This occurred becausethe regional inspection teams (1) did not
                          always include someoneknowledgeable about infection control pro-
                          grams and (2) were given guidance that was not sufficient to assessthe
                          programs. (Seepp. 31-32.)
           Y




                          Page4                                       GAO/HRD90-27VA'sInfectionControlPrograms


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    j                  Executive summary




                       VA does not have a specific headquarters unit to direct its infection con-
                       trol programs. As a result, at least six different offices are issuing guid-
                       ance on infection control related issues,and someof it is confusing and
                       incorrect. In addition, no formal mechanism has been set up to allow
                       infection control practitioners to share information on their programs.
                       As a result, practitioners spend time developing educational programs,
                       as well as policies and procedures that have already been established by
                       other VA practitioners at other medical centers. (Seepp. 32 to 34.)

                       GAO recommendsthat    the Secretary of Veterans Affairs require the
ReJcommendations       Chief Medical Director to

                       update VA guidance so that it includes componentssimilar to GAO'S basic
                       elements (seep. 27),
                       require medical center directors to reexamine the level of support given
                       to their infection control programs and to provide additional support
                       where appropriate,
                   .   incorporate procedures in regional office survey requirements to assure
                       that each medical center’s infection control program is adequately
                       reviewed, and
                   .   designate a unit in VA'S central office to direct and coordinate its infec-
                       tion control programs. (Seep. 36.)


                       VA concurred with GAO'S recommendations and stated that         it had initi-
Agency Comments        ated actions to implement them.




        Y




                       Page6                               GAO/HRD-90-27   VA’sJnfectionControlProgran~s
Executive Summary                                                                                 2

Chapter 1                                                                                         8
Introduction           Importance of Infection Control Programs
                       VA’s Infection Control Programs
                                                                                                  8
                                                                                                  9
                       Costs of Hospital-Acquired Infections                                     11
                       Objectives,Scope,and Methodology                                          12

Chkpter 2                                                                                        16
In&eased Use of Our    Basic Elements of an Infection Control Program                            16
                       VA Staff Use Many Basic Elements on Their Own                             18
Ba$c Elements Could        Initiative
Improve Infection      SomeBasic Elements Are Not as Widely Used as Others                       19    ’
                       Use of One Element Differs Significantly Between VA and                   26
Cobtrol Programs           Nonfederal Sector
  6
                       Conclusion                                                                26
                       Recommendation                                                            27
                       Agency Comments                                                           27

Chapter 3                                                                                        28
Infection Control      Medical Center ManagementDoesNot Emphasize                                28
                           Infection Control
Should Receive More    Inadequate Regional Office Monitoring of Programs                        31
Managerial Attention   Fragmented Central Office Oversight                                      32
                       Conclusion                                                               34
at &ll VA Levels       Recommendations                                                          36
                       Agency Comments                                                          35

Aopendixes             Appendix I: Methodology Used to Develop the Basic                        36
                          Elements of an Infection Control Program
                       Appendix II: Basic Elements of an Infection Control                      37
                          Program
                       Appendix III: Methodology for Sampling Nonfederal                        46
                          Hospitals
                       Appendix IV: VA Medical Centers Visited                                  47
                       Appendix V: VA Medical Centers’ and Nonfederal                           48
                          Hospitals’ Use of GAO’s Basic Elements
                       Appendix VI: CommentsFrom the Department of                              52
                          Veterans Affairs
                       Appendix VII: Major Contributors to This Report                          54


                       Page 6                            GAO/HRD-90-27VA’sinfection Control Progrmns
             Table 2.1: Hospitals That Do Not Have Physician                          20
                 Consultants/Supervisors Trained in Infection Control
             Table 2,2: Hospitals Not Performing CaseFinding at Least                 21
                 OnceEvery 3 Days
             Table 2.3: Hospitals Performing Bloodstream, Pneumonia,                  23
                 and Urinary Tract Infection Analysis, but Not
                 Reporting Results to Ward Supervisors
             Table 2.4: Hospitals That Perform Surgical Wound                         24
                 Surveillance, Analyze the Data, and Do Not Report
                 Results to Practicing Surgeons
             Table 2.6: Hospitals That Conduct Surveillance but Do                    26
                 Not Have Baseline Rates
             Table II. 1: General Elements                                            38
             Table 11.2:Bloodstream Infections                                        39
             Table 11.3:Pneumonia                                                     40
             Table 11.4:Surgical Wound Infections                                     41
             Table 11.6:Urinary Tract Infections                                      43
             Table 111.1:Nonfederal Hospitals-Sample Sizesand                         44
                 ResponseRates by Strata
             Table 111.2:Estimates and Corresponding Sampling Errors                  46
                 for Nonfederal Hospitals

Figure       Figure 2.1: Main Categoriesof Elements in Infection                      17
                 Control Programs




             Abbreviations

             AIDS      acquired immunodeficiency syndrome
             AHA       American Hospital Association
             CDC       Centers for DiseaseControl
             GAO       General Accounting Office
         Y
             IV        intravenous
             SENIC     Study on the Efficacy of Nosocomial Infection Control
             VA        Department of Veterans Affairs


             Page7                             GAO/HRD-90-27VA%Lnfection Control Program
Chabter 1

I$roduction


                    Hospital-acquired infections are a sizable health concern in the United
                    States. The Centers for DiseaseControl (coo) estimates that 6 percent of
                    all inpatients contract at least one hospital-acquired infection during
                    their hospital stays. The Department of Veterans Affairs (VA) operates
                    the largest health care delivery system in the United States and served
                    1,279,976inpatients in 1987. A S-percentrate of infection would suggest
                    that about 64,000 of these patients could have acquired infections.
                    Although these infections can be relatively minor, somecould be life
                    threatening. Even if relatively few of these individuals choseto submit
                    claims against VA for infections contracted while in medical centers, the
                    cost to the government could be significant. Becauseof the importance
                    of infection control, the Ranking Minority Member of the SenateVeter-
                    ans’ Affairs Committee asked us to evaluate VA’S program to control
                    such infections.
   ,
                    Many factors contribute to the prevalence of hospital-acquired infec-
Wportance of        tions. Hospitalized patients tend to be more susceptible to infection than
Infection Control   healthy individuals becausethey are often ill or injured when they enter
Prpgranw            the hospital. Others may becomemore susceptible as the result of sur-
                    gery, insertion of catheters and tubes, or use of other equipment related
                    to hospital care, such as ventilators. Further, patients admitted with
                    infections could exposeother patients to those infections. Visitors and
                    hospital staff also introduce disease-causingorganisms. Health care
                    workers can reduce the spread of infections from one patient to another
                    by following certain practices when caring for patients. These practices
                    can be simple, such as washing their hands before and after providing
                    care to each patient or using the proper technique to insert a needle
                    intravenously.
                    To minimize the incidence of infections, hospitals’ infection control pro-
                    grams monitor and emphasizepatient care practices through two inter-
                    related activities-surveillance and control. Surveillance activities
                    involve (1) identifying patients with hospital-acquired infections and
                    collecting appropriate data to calculate infection rates, (2) analyzing
                    data about those patients and their infections to determine causes,and
                    (3) reporting analyzed data to hospital management and other staff who
                    can use it to identify the causesof infection and weaknessesin their
                    patient care practices. Control activities consist of the specific actions
                    taken to prevent and control infections, such as developing and revising
            Y
                    hospital policies; teaching and reinforcing proper patient care practices;
                    and implementing certain practices, such as the isolation of certain
                    infected patients.


                    Page 8                                 GAO/HRB90-27 VA’sInfection Control Programs



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                              chapter 1
                              Intmduction




-
                              In 1974, CDC began a major study on the efficacy of infection control
                              programs in hospitals.’ The study results showed that when an effective
                              program was present, hospital-acquired infections could be reduced sig-
                              nificantly. The study, which was updated in 1983, covered the four
                              major types of hospital-acquired infections: bloodstream, pneumonia,
                              surgical wound, and urinary tract. Researchersconducting the study
                              estimated that such infections constitute more than 80 percent of all
                              hospital-acquired infections. cnc officials informed us that, generally,
                              the findings of this study are as pertinent today as they were in 1974
                              and 1983. Specifically, if a hospital implements an effective infection
                              control program, it will decreaseits hospital-acquired infection rate.
        I

    i
                              Each VA medical center is required to maintain an infection control pro-
E b’s Infection Control       gram as part of its quality assuranceefforts. VA'S central office provides
PI ~ograms                    general guidance as to how the programs should be conducted and gives
                              medical center directors responsibility for the program. VA'S regional
                              offices are responsible for the general oversight of the centers’ infection
                              control programs.


Medical Center                The directors of VA'S 169 medical centers are responsible for developing
A$ministration of             and implementing their own infection control programs.2The directors
                              receive general guidance from the central office, which includes the
Piograms                      appropriate staffing level for the program and what should be included
                              in surveillance and control activities. In somecenters, infection control
                              may be a part-time responsibility of a single practitioner; in others, the
                              staff may consist of several practitioners.
                              Most of VA’S medical centers are large by hospital standards-61 have
                              400 or more acute-carebeds, and only 9 have fewer than 100 acute-care
                              beds. VA guidance calls for each medical center to have at least one infec-
                              tion control practitioner for every 200 to 250 beds. The duties of these
                              practitioners-generally registered nurses-include
                          l   conducting surveillance to identify infections and potential epidemics,
                          l   analyzing infection data (e.g., trending and calculating infection rates),

            Y
                              ’ CDC’s Study on the Efficacy of Nosocomial Infection Control (SENIC) evaluated the impact of sur-
                              veillance and control activities on hospital-acquired infections in a sample of nonfederal hospitals.

                              “A medical center consists of one or more hospitals and one or more outpatient clinics, and may also
                              include a nursing home and a domiciliary.



                              Page 9                                            GAO/HRJS90-27VA’sInfection Control Programs
                                 chapter 1
                                 Introduction




-
                             . preparing written reports of findings for the centers’ infection control
                               committees,
                             l developing policies and procedures, and
                             l educating patients and staff on infection control practices.

                                 VA guidance also requires each medical center to establish an infection
                                 control committee to be chaired by a physician specially trained in and/
                                 or especially interested in infectious diseases3The committee represents
                                 the center’s departments of medicine, surgery, nursing, laboratory,
                                 pharmacy, supply, medical administration, building management,and
                                 dietetics. The committee also directs the activities of the medical
                                 center’s infection control staff.


Redional Office Monitoring       VA is divided into sevengeographic regions, each responsible for moni-
of JV0gran-k                     toring from 21 to 28 medical centers. Regional directors exercise direct
                                 line supervision over medical centers within their region. They are also
                                 responsible for enforcing VA’S infection control guidance and evaluating
                                 the medical care and related services provided in individual centers.

                                 At the time of our review, the regions’ examination of medical care and
                                 compliance with VA guidance was conducted primarily through visits to
                                 each medical center by a team of health care and administrative person-
                                 nel. Central office officials told us that each center should be reviewed
                                 at least every 3 years. If deficiencies in the infection control program
                                 are found, the center is required to respond with an action plan indicat-
                                 ing the corrective steps that will be taken. Action plans are submitted to
                                 the region and to the central office for review. The region is responsible
                                 for ensuring that final action plans are adequate and that they are car-
                                 ried out.


Central Office Role in           No specific office or person in VA’S central office is directly responsible
Infection Control Efforts        for the infection control program. However, two central office program
                                 units-the infectious diseasesoffice and the nursing service-have
                                 assumedresponsibility for those parts of infection control programs
                                 that relate to their functional responsibilities. These two units have
                                 issued most of the VA guidance used by the medical centers on how infec-
                                 tion control programs should be conducted. In addition, the nursing ser-
              Y                  vice has assignedan infection control liaison function to one of its

                                 “Infectious disease physicians treat patients with infectious diseases, such as hepatitis. However,
                                 these physicians do not necessarily have training in hospital infection control.



                                 Page 10                                           GAO/HRDQO-2’7
                                                                                               VA’sInPection Control Programs
                      Chapt8r 1
                      Introduction




                      nurses in the central office. The liaison function is one of many responsi-
                      bilities assignedto this individual, and no specific infection control pro-
                      gram training is either provided or required for the position. In addition,
                      the liaison only interacts with infection control practitioners who are
                      nurses.
                      In January 1988, VA’S central office appointed a program director for
                      infectious diseasesand gave him responsibility for developing guidance
                      to the medical centers on infectious diseaseissues.This individual is
                      located at a medical center and, in addition to his central office role, is
                      the chief of medicine for his medical center. He has not been allocated
                      any additional staff to assist him with his central office responsibilities,

                      The goal of infection control programs is to prevent infections so that
Cbsts of Hospital-    patients’ suffering and costs to the VA system are minimizedIn 1987, VA
Abquired Infections   paid out over $3 million to close 17 malpractice claims related to
                      hospital-acquired infections. Sixteen of these claims were settled out of
                      court and, therefore, do not represent judgments against VA. However,
                      these claims represent only one type of cost to the VA system. Other costs
                      include the extra days the patient is in the medical center being treated
                      for an infection and the additional cost of diagnosing and treating the
                      infection (e.g., extra laboratory test or intravenous antibiotics).
                      Researchershave estimated that an effective infection control program
                      more than pays for itself by preventing infections and thereby reducing
                      patients’ length of stay and related costs of treating infections.
                      The “cost” to the patient who has an infection varies. For example, uri-
                      nary tract infections are generally the least serious and may causethe
                      patient somediscomfort; bloodstream infections or pneumonia could be
                      fatal if not addressedin a timely manner.
                      In July 1988, the Department of Medicine and Surgery, now the Veter-
                      ans Health Servicesand ResearchAdministration, identified infection
                      control programs as a high-risk area under the Financial Integrity Act.
                      High-risk areas identify potential risks in agency operations that require
                      corrective action or further investigation and should be acted on during
                      the first year they are identified.




                      Page 11                             GAO/HRD-90-27VA’sInfection Control Programs
                            On November 18,1986, the former Chairman of the SenateVeterans’
Olqjektives,Scope,and       Affairs Committee requested that we evaluate VA’S infection control pro-
Mqthodology                 gram. Basedon the Senator’s request letter and discussionswith com-
                            mittee staff, we agreed to determine
                        . if VA medical centers have adequately staffed and organized their infec-
                          tion control programs,
                        . how infection control data are used to help prevent future infections,
                        l the amount of financial lossesresulting from tort claims due to hospital-
                          acquired infections, and
                        l how the VA medical centers’ programs compare with similar nonfederal
                          hospitals’ programs.
                            We conducted this evaluation from June 1987 to June 1989 in accord-
                            ance with generally acceptedgovernment auditing standards.

                            At the inception of this review, we met several times with CDC officials
                            to discuss,from a conceptual perspective, what a good basic infection
                            control program should consist of (Le., a program that would consist
                            only of fundamentals). Drawing from these discussions,we determined
                            that there was no current generally acceptedwritten guidance available
                            to the health care community on what constitutes the basic elements of
                            an effective surveillance programe4Given the lack of guidance, we
                            sought out eight additional organizations recognizedby the medical com-
                            munity as having expertise in infection control, and one infection con-
                            trol expert, to develop a comprehensivelist of elements that might be
                            included in an infection control program in today’s medical environ-
                            ment. Appendix I describeshow the basic elements were developed and
                            gives the organizations and individual we contacted to assist us in this
                            effort.
                            The list developed as a result of these interactions contains 56 basic ele-
                            ments that we believe represent the minimum requirements of an effec-
                            tive infection control program (see app. II). Although the basic elements
                            place emphasis on surveillance activities, control activities are vital to
                            an effective infection control program. We included in our list only
                            broad categoriesof control activities performed by infection control
                            staff becausesomecontrol activities, unlike surveillance activities, are
                            performed not only by the infection control staff but by other hospital
                            4Guidance on infection surveillance programs should be differentiated from guidance on patient care
                            practices related to infection control. CHICguidelines detail recommendations on practices to be car-
                            ried out by providers to prevent infections but specific guidance on surveillance procedures was not
                            available.



                            Page 12                                          GAO/~90-27        VA’sInfection Control Programs
     chapter 1
     Introduction




,
    personnel. Further, the control activities performed by the infection con-
    trol staff depend heavily on the surveillance findings and circumstances
    within the hospital. The basic elements are limited to those appropriate
    for acute-carehospitals with 60 or more beds becauseinfection control
    experts informed us that infection control needsand practices differ for
    hospitals providing long-term care and for hospitals with fewer than 60
    beds.

    We prepared a questionnaire basedon the elements we developed to
    help evaluate the content of infection control programs in VA medical
    centers and to compare VA and nonfederal programs. The questionnaire
    was developed in close consultation with CDCinfection control experts
    and sent to all 169 VA medical centers. Responseswere received from all
    the centers.”However, one VA medical center indicated that it had fewer
    than 60 acute-carebeds and was excluded from our review. We also
    mailed questionnaires to a random sample of 567 nonfederal hospitals
    with 60 or more beds and received 443 usable responses.The data from
    these hospitals were used to make estimates about the universe of
    nonfederal hospitals with 60 or more acute-carebeds (estimated at
    3,872). All of the data on nonfederal hospitals in this report are based
    on our sample and are subject to sampling error. Appendix III describes
    the methodology we used to select the nonfederal hospitals and presents
    the sampling errors associatedwith the estimates for the nonfederal
    hospitals.

    We promised respondents confidentiality to encouragethem to answer
    the questionnaire accurately. In addition, in the letter that accompanied
    our questionnaire to VA medical centers, we stated that we would ask
    some centers to provide documentation to support the accuracy of their
    responses.Later, we requested documentary support for nine questions
    from 32 VA centers (about 20 percent) randomly selectedfrom returned
    questionnaires. We were able to verify 94 percent of the responsesfor
    which we sought documentation. Three percent were incorrect and we
    could not determine the accuracy of the other three percent. We do not
    believe the incorrect and nonvalidated responsesaffect our conclusions
    in this report.
    We also visited sevenVA medical centers to review their infection control
    programs (see app, IV). They were selectedon the basis of size, geo-
    graphic location, and medical school affiliation. We selectedmedium to

    6We also sent the questionnaire to 79 Department of Defense hospitals. We will provide the results of
    that analysis in a separate report on infection control activities in military hospitals.



    Page 13                                          GAO/H&D-90-27VA’sInfection Control Progrruns
Chapter 1
Introduction




large centers from a variety of geographic regions0 Our selection
included five centers that were affiliated with medical schoolsand two
that were not. At each center, we interviewed the director, chief of staff,
infection control staff, service chiefs, department heads, and ward
nurses, as well as officials responsible for the quality assurancepro-
gram. We also reviewed pertinent files and records pertaining to quality
assuranceand infection control surveillance and control activities, and
accompaniedinfection control practitioners on ward rounds to observe
infection control activities and practices within the center.
We met with officials at three VA regional offices to discusstheir moni-
toring of infection control programs and reviewed a selectedsample of
regional survey reports, medical center corrective action plans, and
regional follow-up reports. We also talked with officials from two addi-
tional regional offices to discusstheir monitoring of center’s programs.
At the VA central office, we determined how VA rated the risk level asso-
ciated with infection control under the Financial Integrity Act; inter-
viewed previous and current chiefs of the infectious diseasesprogram
and officials within the offices of quality assurance,medical inspector,
general counsel, nursing services,and building management;and
reviewed files on tort claims closed in calendar year 1987 to identify
those related to hospital-acquired infections. To help validate the accu-
racy of our determinations that these claims were related to hospital-
acquired infections, we asked VA’s medical inspector for verification.
Throughout the review, if questions developed about the basic elements
or about other matters related to our evaluation, we contacted CDCfor
clarification or advice.




“VA has only nine medical centers with fewer than 100 acute-care beds.



Page 14                                         GAO/HRD-!30-27
                                                             VA’sInfection Control Programs
Chapter 2

*creased Use of Our Basic ElementsCobld
  ’ prove Ink&ion Control Programs
T
                       The 66 elements we identified are applicable to both VA medical centers
                       and nonfederal hospitals. Both groups are using many of these elements
                       and the utilization rates for specific elements are similar. (Seeapp. V.)
                       VA infection control staff generally used 44 of the 66 basic elements we
                       developed,practitioners in the private sector generally used 42. Only 16
                       of the elements are clearly required by VA guidance.
                       The elements that were not widely used by either VA or nonfederal prac-
                       titioners include the frequency of surveillance activities for surgical
                       wound infections, urinary tract infections, and pneumonia; the reporting
                       of infections to ward supervisors and surgeons;and the development of
                       baseline infection rates for pneumonia, Failure to utilize these elements
                       hampers the effectiveness of an infection control program.


                       At the inception of this review, we found that VA guidance on infection
B&sic Elements of an   control programs (1) had not been updated since 1979, and (2) included
Infection Control      requirements that were vague and open to interpretation by the practi-
Ptiogram               tioners. Further, the guidance on infection control programs that existed
                       in the health care community in general was either outdated, did not
                       cover all the major componentsof a program, or did not specifically
                       identify the basic elements of a surveillance program. For example, the
                       Joint Commission on Accreditation of Healthcare Organizations was in
                       the processof rewriting its standards on infection control programs.1In
                       addition, researchershad published studies showing the effectiveness of
                       individual program activities in reducing the number of infections, but
                       no one had studied the effectiveness of a comprehensiveprogram since
                       CDC’S  Study on the Efficiency of Nosocomial Infection Control (SENIC).
                       Furthermore, an American Hospital Association infection control hand-
                       book listed 16 surveillance and control activities and stated that someor
                       all of the duties may be performed by the practitioner. The handbook
                       did not differentiate between activities that ought to be performed as
                       part of any basic program and activities that could be considered as part
                       of an optimal program.
                       As discussedon page 12, to fairly evaluate the content of VA’S infection
                       control programs, we worked with several organizations knowledgeable
                       in infection control to identify a set of current basic elements that are
                       flexible enough to apply to different acute-carehospital environments2
                       ‘The revised standards on infection control took effect on January 1, 1990.
                       ‘Hospital environments may differ in the types of clinical services offered, types and amount of
                       available resources, and the number and risk of infections.



                       Page 15                                          GAO/HRD99-27 VA’sInfection Control Programs
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    chapter 2
    Increased Usesof Our Basic Elementa Could
    Improve Infection Control Program9




    The result is a set of 66 elements in five categories:general elements,
    bloodstream infections, pneumonia, surgical wound infections, and uri-
    nary tract infections. Appendix II lists all these elements.The general
    category includes 14 elements that apply to all hospitals and address
    program structure, surveillance activities, and control activities. The
    other four categoriesrepresent surveillance activities specific to the
    major types of infections. The surveillance activities relate to

    identification of infections-what sourcesto use and how often to iden-
    tify infections,
    analysis of infections -what factors should be analyzed to determine
    the causesof an infection, and
    reporting of infections -which hospital officials should receive ana-
    lyzed infection data.
    Figure 2.1 cites specific examples of the elements that are included in
    each of the categories.




    Page 16                                     GAO/HRD-90-27VA’sInfection Control Programs
                                               brewed     Uw of Our Bah Ellemente Could
                                               Improve Infection Control Program




ire 2.1: Main Categories         of Element8
hction        Control Program8                 caiogory                         Examples of Basic Elements


                                                 General (14 elements)             l The infection control committee meets at least
                                                                                     every 2 months.
                                                                                   0 The hospital’s infection control program has
                                                                                     written standardized criteria (definitions) for
                                                                                     hospital-acquired infections at specific sites.
                                                                                   l The hospital’s infection control program assists in
                                                                                     identifying and developing topics for in-service
                                                                                     training.



                                                                                   ldentlflcatlon
                                                                                   l   A hospital’s infection control program uses at
                                                                                       least one of the following case-finding approaches
                                                                                      to identify bloodstream infections either in all
                                                                                       patients or in a subset of patients:
                                                                                      l    review of patients’ blood cultures
                                                                                      4 review of patients’ charts
                                                                                      l    review of patients’ fever charts



                                                 Pneumonla Surveillance            ldentlflcatlon
                                                 (11 elements)                     0 During the surveillance period, a hospital’s infection
                                                                                      control program performs an acceptable case-
                                                                                      finding approach on an average of every 3 days.



                                                Surgical Wound Infectlon           Analysis
                                                Surveillance (13 elements)         0 The infection control staff analyzes surgical
                                                                                     wound infection data by surgeon.



                                                                                   Reportlng
                                                                                   0 The infection control staff reports ward-specific
                                                                                     summarized/analyzed data on hospital-acquired
                                                                                     urinary tract infections to the ward supervisors or
                                                                                     head nurses.



                                               Our basic elements allow for two different surveillance approaches:
                                               total surveillance or targeted surveillance. Under total surveillance, an
                                               infection control practitioner searchesfor all four major types of infec-
                                               tion in every hospital patient, on either a periodic or a continuous basis.
                                               Practitioners performing this type of surveillance would generally use



                                               Page 17                                    GAO/HRD-90-27VA’sInf’ection Control Programs



         a.
                       chapter 2
                       Increased Ule of Our Basic Elementa Could
                       Improve Infection Control Programn




                       61 of our 66 elements.3Under targeted surveillance, the areas of highest
                       risk or concern are periodically identified, and the infection control
                       practitioner focuseson those areas. For example, for a specified period
                       of time a hospital may elect to search for one or more of the infection
                       types in only high-risk patients, such as those in the intensive care unit.
                       Under targeted surveillance, 14 general elements would always apply,
                       and the remaining elements used would depend on the specific infection
                       types (bloodstream, pneumonia, surgical wound, or urinary tract) being
                       targeted in the high-risk patients.
                       The type of surveillance used dependson the staff available and the
                       special requirements or interests of the hospital or medical center. CDC
                       officials stated that, in the 19709,medical authorities believed that all
                       hospitals should conduct total surveillance. Sincethat time, experts
                       have acknowledged that infection control program resourcesare better
                       spent focusing on patients with a high risk of infection, such as those in
                       the intensive care unit, where the impact from reducing infections is
                       greater. Thus, targeted surveillance can be an acceptableapproach.

                       Forty-four of the 66 basic elements were being used by at least 70 per-
VA Staff Use Many      cent of VA medical centers when such use was appropriate.4 Similarly, 42
Basic Elements on      of the sameelements used by VA centers were being used by at least 70
Teeir Own Initiative   percent of the nonfederal hospitals when appropriate. The other ele-
                       ments were also used by someVA medical centers and nonfederal hospi-
                       tals, but to a more limited extent.

                       VA’s guidance on infection control programs clearly requires only 16 of
                       the 66 basic elements we developed: 17 of our basic elements are not
                       included in VA’S guidance and the other 23 are discussedin such vague
                       terms that the guidance is of little use to the practitioner. For example,
                       our basic elements indicate that ward supervisor@should receive data,
                       analyzed by ward, on bloodstream infections, urinary tract infections,
                       and pneumonia. However, VA guidance states only that the practitioner



                       “The five remaining elements include activities that are applicable when targeting certain types of
                       infections (e.g., analyzing hospital-acquired bloodstream infection data by whether or not the patient
                       had an intravenous (IV) catheter).

                       4Ekcause not all centers and hospitals need to use all elements, when we calculated percentages we
                       included only those centers in which the element was applicable.

                       “We use the term “ward supervisors” to also refer to “head nurses.”



                       Page 19                                           GAO/HRD-90-27VA’sInfection Control Programs
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                             should prepare a report for “appropriate personnel” and allows infec-
                             tion control staff to decide who is appropriate and what is to be
                             included in the report.

                             At five of the sevenVA medical centers we visited, the practitioners took
                             the initiative to take training, contact others both inside and outside VA,
                             or read literature concerning infection control programs. As a result,
                             they included activities in their programs that went beyond VA guidance
                             and adhered to many of our basic elements.

                             Certain elements we identified were not used on a consistent basis by
  )me Basic Elements         infection control programs in either VA or the nonfederal sector.” These
  re Not as Widely           elements relate to
  sed as Others -        . the availability of a trained physician consultant for the infection con-
                           trol program,
                         l the frequency with which surveillance activities should take place,
                         l the submission of infection control analysesto personnel who can use
                           them, and
                         . the development of a baseline rate for pneumonia.

                             While we did not ask respondentsto our questionnaire why these ele-
                             ments were not used as frequently as the others, VA’S Chief of Infectious
                             Diseasessaid that these elements require resourcesthat are not always
                             available to the medical center. In addition, in the caseof VA, none of
                             these elements were clearly required in its guidance.


Trained Physician            One of our elements calls for infection control programs to have, as a
Consultants Needed for       consultant or supervisor, a physician who has taken at least one training
                             course in hospital infection control. This element has a relatively low
Ibfection Control            utilization rate in both VA medical centers and nonfederal hospitals when
Programs                     compared with most other elements. According to VA practitioners who
                             filled out our questionnaire, 166 VA medical centers have a physician
                             available to the infection control staff as a consultant or supervisor. But
                             63 of these physicians had not received any training in hospital infec-
                             tion control.



                             “We define “consistent basis” as when 70 percent or more of the medical centers or nonfederal hospi-
                             tals use the element.



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                                  Chapter 2
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                                  cnc’s SENIC found a correlation between fewer infections and programs
                                  with a physician supervisor trained in infection control. While this
                                  study is now dated, cnc officials still believe that trained physician con-
                                  sultants or supervisors are an important factor for an effective infection
                                  control program.
                                  VA’s guidance doesnot require an infection control advisor to have infec-
                                  tion control training -it is optional. Specifically, VA guidance states that
                                  the chairman of the infection control committee should be a physician
                                  who is specially trained in or especially interested in infectious diseases.
                                  Many nonfederal hospitalsalso had infection control physician consul-
                                  tants or supervisors who had not taken at least one training course in
                                  hospital infection control. Further, large VA centers and nonfederal hos-
                                  pitals were more likely to have a trained physician than their smaller
                                  counterparts. Table 2.1 provides a comparative analysis of the utiliza-
                                  tion of this element by VA and nonfederal hospitals.

Phyqiclan Conrultants/Supewiron                                    Number of             Hoapitala without a trained
Traitled In Infection Control                                      applicable             infection control physician
                                  Hospital8                         hOspitEd           Number                      Percent
                                  Under 400 beds:
                                  VA                                           97            47                          48
                                  Nonfederal                                3.363         1.817                          54
                                  400 or more beds:
                                  VA                                          61            19                           31
                                  Nonfederal                                 509           233                           46



N&d for Frequent                  Our basic elements call for an infection control practitioner to take steps
Surveillance                      at least every 3 days to (1) determine which hospital patients may have
                                  infections and (2) identify infections before a patient’s discharge. This
                                  activity-called casefinding-can be done by reviewing laboratory cul-
                                  tures or patient charts, and/or asking nurses about patients with signs
                                  or symptoms of infection. These activities are time consuming and
                                  require the practitioners continual attention, but performing them every
                                  3 days allows the infection control staff to identify problems and take
                                  corrective action before the infections get out of control. CDC officials
                                  believe that a frequency of at least every 3 days is necessarybecause
                                  hospitals are emphasizing shorter lengths of stay for patients. Thus, if
                     0            casefinding is not done within this time frame, patients with an infec-
                                  tion may not be identified by the program before discharge.



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                                      With the exception of surgical wound infection surveillance, current VA
                                      guidance doesnot addressthe frequency with which surveillance should
                                      be performed. For surgical wound infections, a surgical services direc-
                                      tive states that such surveillance should be performed daily by surgical
                                      service personnel. The guidance doesnot mention the infection control
                                      staff’s responsibility in this area.
                                      Our questionnaire results indicated that infection control practitioners
                                      at most VA medical centers were performing casefinding at least every 3
                                      days for bloodstream surveillance but almost half were not doing so as
                                      frequently for surgical wound, pneumonia, and urinary tract surveil-
                                      lance. Many infection control practitioners in nonfederal hospitals indi-
                                      cated a similar pattern of casefinding. Table 2.2 comparesthe
                                      utilization by VA and nonfederal hospitals of our case-finding elements
                                      pertaining to surgical wound, pneumonia, and urinary tract infections.

Pinging at Leabt once Every 3 Daya”                                     Number of
                                                               hO8pitai5 to which                    iiO8Pitai8   not adhering    to element
                                      Category/hospital          element applies                    Number                              Percent
                                      Cabe finding for surgical wound infections:
                                      VA                                             131                  55                                   42
                                      Nonfederal                                   3.732               1.671                                   45
                                      Case finding for pneumonia:
                                      VA                                             141                  62                                   44
                                      Nonfederal                                   3,546               1,419                                   40
                                      Cabe finding for urinary tract infections:
                                      VA                                             141                  66                                   47
                                      Nonfederal                                   3,586               1,631                                   45
                                      % this and other tables to follow, when we report the results of our analysis for the universe of VA
                                      medical centers and the projected universe of nonfederal hospitals, it is because we did not find signifi-
                                      cant differences between VA and nonfederal responses by hospital size.

                                      In contrast to the aforementioned utilization rates, only 26 (17 percent)
                                      of the 162 VA medical centers and 606 (17 percent) of 3,643 nonfederal
                                      hospitals performing bloodstream surveillance did not perform case
                                      finding for bloodstream infections every 3 days. One possible explana-
                                      tion for the higher use rate is that the case-finding activities associated
                                      with bloodstream infections are less time consuming than those required
                                      for other infections. Case-finding for bloodstream infections can be done
                                      through a review of laboratory results, whereas identifying the other
                                      three types of infections require more time-consuming methods. These
                                      methods include a review of laboratory results coupled with discussions
                                      with nurses about signs and symptoms of infection in patients or an


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                                Chapter 2
                                Increased Use of Our Basic Element8 Could
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                                examination of patients’ medical records. VA’S program director for
                                infectious diseasessaid that these elements were not being used in VA
                                becausethe activities are labor intensive and the infection control pro-
                                grams are understaffed.


Inf ’ ction Control Data        Infection control experts indicate that pertinent data on infections
Sh uld Be Reported to           should be reported to hospital personnel who can take action to prevent
                                infections. Thirteen of our basic elements identify specific personnel to
Pei onnel Who Can Take          whom certain data analyses should be provided (e.g., urinary tract
Preiventive Actions             infection data should be analyzed by ward and given to the ward super-
                                visor). VA guidance requires only that the infection control staff “pre-
                                pare a written report for the Infection Control Committee and other
                                appropriate personnel.” The guidance doesnot elaborate on what the
                                written report should contain, and the determination of who are “appro-
                                priate personnel” is left to the discretion of the infection control staff.
                                Despite the lack of guidance on who should receive infection control
                                reports, nearly all VA medical centers generally used 6 of these 13 ele-
                                ments. Specifically, at least 90 percent of the VA medical centers
                                reported appropriate data on infections to the infection control commit-
                                tee and/or surgical wound infection data to the chief of surgery and
                                operating room supervisor. The other seven elements were used, but to a
                                lesser extent. The elements with relatively low utilization rates involve
                                reporting to ward supervisors, practicing surgeons,and various other
                                hospital groups, such as respiratory therapy teams.

Reporting to Ward Supervisors   Our basic elements state that medical facilities that perform blood-
                                stream, pneumonia, or urinary tract infection surveillance, should ana-
                                lyze their data by ward and report that information to ward
                                supervisors. Our questionnaire results reveal that over 95 percent of the
                                VA medical centers that perform surveillance on each of these types of
                                infections did analyze by ward. But many did not report this infection
                                data to ward supervisors. Hospitals in the nonfederal sector that ana-
                                lyzed infection data by ward reported this data to ward supervisors
                                with about the same frequency as their VA counterparts. Table 2.3 com-
                                pares the utilization of these elements by VA and nonfederal hospitals.


                Y




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                                           chapter 2
                                           Increaeed Ueeof Our Be&c Elements Could
                                           Improve Infection Control Progrema




Tab   e 2.3: Horpltalr  Performlng
810    detresm, Pneumonla, and Urinary                                           Number of
Tra   t lnfectlon Analy818, but Not                                               hospital8      Ho8pltal8 not reporting analyrk
Re    ortlng Rerults to Ward Supervlrorr                                        performln          results to ward 8UPerVl8Or8
                                           Category/hospital             analysis by war 3       Number                    Percent
  i                                        Bloodstream rurvelllance:
                                           VA                                          148            52                         35
                                           Nonfederal                                2,988           962                         32
                                           Pneumonia    8urvelllance:
                                           VA                                          135            47                         35
                                           Nonfederal                                2,928           789                         27
                                           Urinary tract surveillance:
                                           VA                                          139            44                         32
                                           Nonfederal                                3,051           708                         23


Reporting to Practicing Surgeons           Studies by various infection control researchersindicate that reporting
                                           surgical wound infection rates to the surgeonswho perform the opera-
                                           tions has a major effect on reducing infections. Several infection control
                                           experts argue that reporting surgeon-specificrates is essential if an
                                           infection control program is to have any successin preventing surgical
                                           wound infections.

                                           Our basic elements call for the analysis of surgical wound infection rates
                                           by surgeon and the reporting of the surgeons’ specific infection rates
                                           back to them. Thus, each surgeon would receive information about the
                                           infections contracted by his or her patients. VA’S program director for
                                           infectious diseasesstated that analysis of surgical wound data by sur-
                                           geon is time consuming and requires adequate staffing to be done cor-
                                           rectly. But once the analysis is done, reporting the data to surgeons
                                           should not be time consuming. However, he also indicated that surgeons
                                           may not be receptive to the infection control staff’s analysis of surgical
                                           wound data becausethey generally believe that without their involve-
                                           ment in the collection and interpretation of these data, the data could be
                                           misinterpreted.
                                           Table 2.4 compares utilization rates on these elements of VA medical cen-
                                           ters and nonfederal hospitals.




                                           Page 23                                     GAO/HRD9@27VA’sInfection Control Programs
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                                  Increased Use of Our Basic Elements Could
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       Horpltalr   That Perform
                                                                                           tiO8pltal8 IlOt
                                                            Hospitals                          reporting     Percentage not
                                                          performlng          HO8pitalS         Ofl8ly8i8           reporting
                                                     surgical wound     analyzing data         results to            an8ly8i8
                                  Horpltal               surveillance       by surgeon           surgeon               results
                                  VA                              131                 93               72                   77
                                  Nonfederal                    3.732              2.973            2.234                   75


Re rting to Other Groups          Our basic elements include the reporting of pneumonia infection rates to
                                  the respiratory therapy department and bloodstream infection rates to
                                  the intravenous therapy team. In both instances, these personnel pro-
                                  vide direct patient care and would benefit from knowing such infection
                                  rates. Questionnaire results indicated that of the 66 VA medical centers
                                  with respiratory therapy teams, 36 did not have infection control pro-
                                  grams that reported the results of pneumonia surveillance back to the
                                  teams, Only nine VA medical centers doing bloodstream surveillance have
                                  intravenous therapy teams, and sevenof these teams did not receive
                                  data from the infection control program.

                                  In the nonfederal sector, of the 1,064 infection control programs at hos-
                                  pitals with respiratory therapy teams, 426 did not report the results of
                                  pneumonia surveillance back to the teams. Of the 494 nonfederal hospi-
                                  tals doing bloodstream surveillance that have intravenous therapy
                                  teams, 214 teams did not receive data from the infection control
                                  program,
                                  Our basic elements also require infection control program personnel to
                                  provide surgical wound infection data to the surgical complications com-
                                  mittee, which is responsible for reviewing surgical complications, includ-
                                  ing infections. The purpose of this element is to assurethat this
                                  committee receives complete and accurate information on surgical
                                  wound infections since they discusssurgical complications and actions
                                  to prevent them in the future. Further, in our opinion, the discussions
                                  can be enhancedif information collected by the infection control staff is
                                  analyzed before it is submitted to the committee so that trends can be
                                  identified. At the present time, the committee usually relies on physi-
                                  cians to report on complications causedby surgical procedures; research
                                  indicates that self-reporting doesnot provide complete information.
                                  Questionnaire results revealed that the infection control staff at 39 (42
                                  percent) of the 92 VA medical centers that monitored surgical wound
                                  infections with surgical complications committees, did not share surgical



                                  Page 24                                     GAO/HRD-90-27VA’sInfection Control Programs
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                               wound surveillance data with the committee, In the nonfederal sector,
                               infection control staff in 746 (38 percent) of the 1,976 hospitals that
                               monitor surgical wound infections with surgical complications commit-
                               tees did not share pertinent data with the committee.


ed for Baseline Rates by Baseline infection rates give a hospital an indication of its “normal”
pe of Infection          level of infection. These rates represent the frequency with which a spe-
                         cific type of infection occurs within a targeted population in a particular
                               hospital based on past surveillance. For example, surveillance conducted
                               on bloodstream infections at a given hospital over the last 2 years may
                               show a l-percent bloodstream infection rate. This percentagebecomes
                               the baseline from which future rates will be measured.
                               Current VA guidance states that baseline rates should be established but
                               does not specify how they should be calculated. Our basic elements spe-
                               cifically require baseline rates to be developed by each of four types of
                               infection-surgical wound, urinary tract, bloodstream, and pneumo-
                               nia-because the risks and causesof infections vary by type. Although
                               VA medical centers generally calculated baseline rates for surgical
                               wound, bloodstream, and/or urinary tract infections, 31 percent of the
                               centers did not calculate rates for pneumonia. VA’S program director for
                               infectious diseasesbelieves that the data for calculating such baseline
                               rates are readily available but noted that VA guidance should more
                               clearly stress the importance of developing baseline rates for each type
                               of infection.

                               As shown in table 2.6, with the exception of baseline rates for surgical
                               wound surveillance, VA medical centers and nonfederal hospitals were
                               similar in their use of our elements concerning baseline rates.




                               Page 26                                       GAO/Hl?D9O-27VA’sMe&ion Control Programs
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                                         lncreasod Urn of Our Bmic Element4 could
                                         Improve InfectIon Control Program9




       ,
        5: Hpapltala That Conduct
Surveil ante but Do Not Have Baclollne                                      Number of
Rate8                                                                         hoapltals
                                                                           conducting           Hospitals   without baseline     rate
                                         Category/hoapltal                clurveillance        Number                          Percent
                                         Bloodstream surveillance:
                                         VA                                           152            41                              27
                                         Nonfederal                                 3,648         1,327                              56
                                         Surgical   wound rurveillance:
                                         VA                                           131            16                              12
                                         Nonfederal                                 3,732           970                              26
                                         Pneumonia     crurveillance:
                                         VA                                          141             44                              31
                                         Nonfederal                                 3,546         1,150                              32
                                         Urinary tract surveillance:
                                         VA                                           141            38                             27
                                         Nonfederal                                 3,586         1,026                             29



                                         One basic element was used significantly less in the nonfederal sector
Us4 of One Element                       than it was in VA medical centers. This element requires that infection
Differs Significantly                    control practitioners and registered nurses have authority to implement
EktkveenVA and                           isolation procedures in an emergencywithout a physician’s order; this
                                         authority should be in writing. Questionnaire results indicated that only
Nonfederal Sector                        19 percent of VA centers with 100 to 399 beds and 23 percent of those
                                         with over 400 beds did not have written authority. Conversely, about 42
                                         percent of nonfederal hospitals with 100 to 399 beds and 46 percent of
                                         hospitals with over 400 beds did not have written authority.

                                         The basic elements we developed are fundamental, generally accepted
Coklusion                                by infection control practitioners in both the public and private sectors,
                                         and supported by organizations knowledgeable about infection control.
                                         Cumulatively, they form the basis for an effective infection control pro-
                                         gram whether in VA or nonfederal hospitals.
                                         Infection control programs in both VA and the nonfederal sector are
                                         using most of the elements we developed. This is happening becausethe
                                         practitioners are taking the initiative to determine what elements should
                                         be used in an effective infection control program. But VA'S written guid-
                                         ance on the subject lags well behind the practitioners’ activities and, in
                                         many cases,is so general that it is of questionable value. We believe that



                                         Page 26                                     GAO/HRIMO-27VA’sInf’ection Control Programs
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                    tncreaeed Urn ofOur Bade Element.4Cimld
                    improve Infection Control Program




                    the use of the elements we identified, included in a basic infection con-
                    trol program, could improve the effectiveness of VA’S programs.
    I
                    We recommendthat the Secretary of Veterans Affairs direct the Chief
  R&commendation    Medical Director to update VA infection control guidance. At a minimum,
                    the guidance should require components similar to those in our basic
                    elements.
    I
    I
                    By letter dated November 21,1989, the Secretary of Veterans Affairs
  Alpmcy Comments   concurred with our recommendation and indicated that VA infection con-
    /               trol guidance would be revised to incorporate our basic elements.




                    Page 27                                   GAO/HRD-90-27 VA’sInfeztion Cbntrol Pmgrama
Chap& 3

Infection Control Should ReceiveMore                                                                          ’
M&mgerid Attention at All VA Levels

                            Although our questionnaire showed that VA infection control programs
                            used most of our basic elements (seech. 2), a questionnaire cannot cap-
                            ture how well these programs were integrated and supported through-
                            out the VA system. Lack of managementsupport and attention can
                            undercut the programs’ effectiveness.

                            Infection control programs at several of the medical centers we visited
                            were understaffed and not well directed or monitored by the responsible
                            VA offices. Of the sevenmedical centers we visited, four of the infection
                            control programs were understaffed. At the central office level, no sin-
                            gle office is responsible for directing the infection control programs and
                            coordinating guidance. Instead, guidance is developed and issued by six
                            different offices. This has resulted in confusing or inaccurate guidance.
                            Further, regional office surveys conducted at six of the sevenmedical
                            centers did not always identify existing deficiencies. As a result of these
                            situations, infection control programs were not as effective as they
                            could have been.

                            Infection control is one of many medical center programs competing for
Medical Center              relatively scarceresources.It is also a program that affects many center
Mtiagement Does Not         activities. At five of the sevenmedical centers we visited, center direc-
Embhasize Infection         tors had either not given the program adequate resourcesto accomplish
                            its objectives or not enforced participation in the program by all clinical
Co&r01                      services of the center. This reduced the program’s effectiveness.


Medical Center              In calendar year 1987,82 of VA’s168 infection control programs were
Mariagement Did Not         understaffed. Our criteria for determining the adequacy of staffing is
                            based on VA guidance, which calls for one infection control practitioner
All&ate Adequate            for every 200 to 260 occupied beds. Of the sevenmedical centers we
Resourcesto the Infection   reviewed, four did not meet this staffing standard, and the practitioners
Control Program             at these centers stated that they did not have time to perform someof
                            the essential infection control activities. For example, at one of the cen-
                            ters, the practitioner collected all the necessarydata on surgical wound
                            infections but had no time to analyze them and, thus, did nothing with
                            them.
                            The directors of two of the understaffed medical centers said that they
                            were each planning to hire another nurse as an infection control practi-
                            tioner. A third medical center director told us that he could not allocate
                            another nurse to infection control becausenurses were in short supply.



                            Page 28                             GAO/HRD-90-27VA’sInfection Control Programs
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    Infiwtlon Cbntrol Slmld ltecdve Mom
    Managerial Attention at All VA bveb   :




    But adding staff is not the only solution available, For example, the
    infection control program at the fourth understaffed medical center (the
    center had one 40-hour-per-week practitioner for 316 occupied beds),
    met all our basic elements by assigning specific responsibility for parts
    of the infection control program to medical center services (e.g., nursing,
    surgery, and medicine). Somecenter serviceswere responsible for con-
    ducting training classeson new infection control policies while others
    were responsible for monitoring the staff’s patient care practices and
    documenting their findings. This gave the practitioner time to collect
    and analyze data on infections and prepare reports to the infection con-
    trol committee and others. We believe this coordination worked at this
    center becausethe chief of staff and center director, through their
    actions, emphasizedinfection control. Further, at this center, the chief
    of staff chaired the infection control committee.

    In our opinion, VA medical centers should have a designated person who
    can perform certain infection control activities when the infection con-
    trol practitioner is absent. This designated person should be trained to
    perform basic infection control activities so that the program doesnot
    stop while the practitioner is away. Four of the seven centers we visited
    had only one practitioner and no one to perform this function when he
    or she was absent. At one of these medical centers, during the week the
    practitioner was away, the center had a number of patients who devel-
    oped a bacterial infection. When the practitioner returned, she found
    that the infection started with two patients in the medical intensive care
    unit who were moved to the surgical intensive care unit. This infection
    had spread to sevenother patients by the time the practitioner returned.
    The practitioner speculated that had she been in the center or had a
    backup, the source of the infection would have been identified earlier,
    the patients who had contracted it would have been treated earlier, and
    perhaps someof the spread prevented.
    In addition to staffing, other resourcesare neededto carry out an effec-
    tive infection control program. Since at least 1984, infection control
    practitioners throughout VA have asked the central office for computer
    support, and central office officials have said that infection control
    should be given priority for computer time within a center. But the prac-
    titioners were also told by central office personnel that such support is a
    local policy issue and that they would have to compete for such
    resourcesat the center level. The need for computer support apparently
Y
    still exists at 65 medical centers becausethose practitioners indicated
    through their questionnaire responsesthat they need more computer
    support (e.g., personal computers, software, and training). Further, in


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                        Chapter 3
                        Infection Control Should ReceiveMore
                        Managerial Attention at AU VALevel




-?-
                        the sevencenters we visited, only two practitioners were using a com-
                        puter to perform data analysis on infections. Practitioners that were not
                        using computers cited the need for such equipment and indicated that a
                        computer would also help easethe burden of the understaffing because
                        analysis by computer is faster.

                        At one medical center we visited, the chairperson of the infection con-
                        trol committee delayed surveillance on surgical wound infections for 1
                        year because,without a computer, the practitioners would, not have time
                        to analyze the data collected. Two days before our arrival at this center,
                        the infection control practitioners started their surveillance of surgical
                        wound infections becausethey had just obtained accessto a computer
                        and, therefore, could perform timely analysis of the data collected.
                        Three months later, the physician who headed the program indicated
                        that, as expected, the computer analysis showed that the surgical infec-
                        tion rate for clean surgeries was higher than reported in previous years.’


Medical Center          To foster an effective infection control program, all serviceswithin a
Mahagement Gives        medical center must actively support and participate in it. At five of the
                        seven medical centers visited, it appeared that infection control was not
Infhtion Control        considered a centerwide program, and somemedical center components
Probrams Low Priority   gave it limited attention. For example, we found center directors, medi-
                        cal service chiefs, and other key center officials who (1) did not assure
                        that their representatives attended infection control committee meet-
                        ings, (2) indicated that infection control surveillance was unimportant,
                        and (3) were unaware of infection control issueswithin their centers. At
                        one center, the chief of medicine relied on his “intuitive insights” to
                        identify problems from infections rather than on reviews of the infec-
                        tion control practitioner’s information.
                        Infection control programs can be enhancedwhen there is interest and
                        teamwork within a center, starting with center management.For exam-
                        ple in early 1986, the infection control practitioner at one center we
                        reviewed noticed that a large number of vascular surgery patients who
                        should have had a low risk of infection (their surgery would be classi-
                        fied as clean) had wound infections. She began investigating this but,
                        becauseof concernswith infections occurring in cardiac surgery, had to
                        stop and focus her efforts on cardiac surgery. During this period, the
             Y
                        ‘Surgical wounds can be classified into four wound categories (clean, clean-contaminated, contmi-
                        nated, and dirty) according to their risk of infection. Clean wounds have the lowest risk of infection
                        and dirty wounds have the highest.



                        Page 30                                           GAO/HID-99-27 VA’sInfection Control Programe
   .


                        Chapter 8
                        Infection CmWol Should hcelve More
                        Manngeti Attention at All VA Levels




                        chief of vascular surgery left VA and a new chief was appointed. Upon
                        arrival at the medical center the new chief noted that infection control
                        practices were being neglected by his residents and staff. Within 2


T---                    months, with input from the practitioners, he developed a policy manual
                        for his department. It included infection control practices that he
                        enforced. At the time we visited (March 1988), his department had had
                        no infections on clean surgeries since September 1986.

                        At the time of our review, regional offices were required to conduct a
In dequate Regional     general survey of the effectiveness of the medical centers and their
0 $fice Monitoring of   quality assuranceactivities at least every 3 years. During this survey,
P~ograxns               an examination was to be made of how infection control programs were
                        being implemented. Our review showed that regional offices may not
                        always perform this function. Further, the teams formed by the regional
                        offices to conduct the general survey did not always include personnel
                        knowledgeable in infection control, and the guidance given to teams to
                        review a medical center’s performance may not have been appropriate
                        to measure performance accurately.
                        In 1986 and 1987, the regional offices had surveyed six of the seven
                        medical centers we reviewed. Three of the regional office survey reports
                        made no mention of infection control. But our examination of infection
                        control programs at these centers revealed that at the time the regional
                        office survey was made deficiencies that should have been identified
                        and reported were present in two programs. For example, at one center
                        we found that infection control practitioners were identifying surgical
                        wound infections by using culture results. But officials knowledgeable in
                        infection control told us that many surgical wound infections are not
                        cultured. Therefore, another identification method, such as asking ward
                        nurses about infections, should also be used. In addition, the practition-
                        ers were not aware that the chief of surgery was discouraging his staff
                        from culturing obviously infected surgical wounds. The chief of surgery
                        believed that as a result of this miscommunication practitioners were
                        missing about 20 percent of the wound infections.
                        Of the three regional office survey reports that mentioned infection con-
                        trol, two did not discussproblems that we found during our review. Spe-
                        cifically, one report, dated May 1987, mentioned infection control only
                        to the extent that surgical wound infections were not being categorized
                        by type of wound; that is, clean, contaminated, or dirty wounds. But we
                        found that the practitioner at this center was not performing surgical
                        wound infection surveillance. The acting chief of surgery was tracking


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                             Chapter 3
                             Infection Control Should Receive More
                             Managerial Attention at All VA Levels




                             wound infections on certain surgeries becausethe infection control pro-
                             gram was understaffed and could not monitor such infections. In the
                             acting chief’s opinion, however, surveillance by the infection control
                             practitioner was still needed.This should have been noted in the
                             regional office report.

                             VA has not  given any one office responsibility for providing infection
Fragmented Central           control guidance to its medical centers. As a result, at least six program
Off ice Oversight            offices within the central office have issued guidance to the medical cen-
                             ters on infection control and this guidance is sometimesconfusing or
   /                         inaccurate. In addition, practitioners do not know whom to contact
                             when they have questions regarding infection control, and the central
                             office has no mechanismto share medical centers’ information related to
                             infection control. Therefore, practitioners spend time developing poli-
                             ties, procedures, and educational programs that have already been
                             developed by practitioners at other VA medical centers.


Infection Control Guidance   Six different program offices in VA’S central office have issued guidance
Is Not Coordinated by the    relating to infection control. As a result, such guidance sent to the medi-
                             cal centers can be confusing or inaccurate. The need for someonein VA’S
Ceritral Office              central office to coordinate such guidance was recognizedas early as
                             1984 at a conferenceof infection control practitioners. The two central
                             office officials at the meeting, the nursing services’ infection control liai-
                             son and chief of infectious diseases,said that they would look into the
                             concernsand write a proposal. However, this was not done.
                             Guidance that has not been coordinated can causeconfusion among
                             practitioners. For example, in 1984, VA’S engineering servicesissued
                             guidance to the medical centers on infectious waste that required need-
                             les to be capped while being carried. Central office officials told us that
                             they received numerous calls from medical center nurses indicating that
                             the engineering guidance was wrong. The guidance implied that needles
                             should be recapped after use whereas CM:recommendedthat needles
                             should not be recapped. CDCmade this recommendation to decreasethe
                             incidence of nurses sticking themselves when recapping a used needle,
                             which could causeblood-borne infection, such as acquired immu-
                             nodeficiency syndrome (AIDS) or hepatitis. To clear up the matter, the
                             central office nursing service issued a clarification of this circular to all
             Y
                             center personnel indicating that needlesshould only be capped before
                             being used on a patient and that after use they should be discarded in a
                             puncture-proof container.


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                          Infection Control Should Receive More
                          Managerial Attmtlon at AU VA Levels




                          The fact that different offices issue infection control guidance has also
                          causedcommunication problems. This was recognizedin 1987 by the
                          AIDSprogram director (former chief of infectious diseases)at VA’S central
                          office. At that time, she noted that many practitioners had not received
                          appropriate bulletins becauseno one program office distributes infec-
                          tion control guidance. For example, medical centers rely on the infection
                          control practitioners to handle AIDSissues,But the practitioners were
                          not receiving all the Ams-relatedguidance. Thus, at a meeting of the
                          practitioners, the AIDS program director listed all the guidance address-
                          ing AIDS issues.This was the first time many of the practitioners had a
                          complete set of AIDS-relatedguidance.


I&ection Control          VA has not implemented a formal, structured mechanism for practition-
Pkactitioners Duplicate   ers to share ideas and disseminate information among themselves. As a
                          result, practitioners spend time developing program activities that may
Efforts                   already have been developed at another center. At three of the seven
                          centers we reviewed, practitioners commentedthat they were frustrated
                          over “reinventing the wheel” in their program. In their opinion, other
                          practitioners within VA might have developed procedures, policies, or
                          training programs that could be used in their own programs, This con-
                          cern was also raised in meetings of VA practitioners held in 1984, 1986,
                          and 1987. For example, at the 1984 meeting, VA practitioners stated that
                          a compilation of infection control procedures and policies would be help-
                          ful to practitioners. If such a document were available, they would not
                          have to write new policies and procedures but could modify others for
                          their center. As of July 1989, this had not been done.
                          In responseto practitioners’ requests, vAcentral office officials sug-
                          gestedthat they consider developing a communication network among
                          centers. However, the practitioners had already set up an informal net-
                          work to share information among themselves. This network encourages
                          practitioners to participate in the annual conferenceof the Association
                          of Practitioners in Infection Control, where VA practitioners discuss
                          areas of mutual interest. At the initiative of members of the informal
                          network, such meetings were held annually during the 1984 to 1988 con-
                          ferences. The practitioners involved in the network have identified a
                          number of efforts that would help make their programs more efficient.
                          For example, someVApractitioners have developed videotapes to edu-
                          cate staff on certain practices to prevent infections. The network was
           Y
                          trying to identify those centers with educational tapes and set up a
                          mechanism by which other centers could borrow or copy the tapes.



                          Page 33                                 GAO/IiRD-90.27 VA’sInfection Control Program8
             Chapter 8
             InfectIon Control Should RecedveMore
             Managerial Attention at All VA Levels




             Many of the practitioners we talked with stated that the informal net-
             work is very beneficial, but they believe the central office should under-
             take a more formal coordination of infection control procedures and
             policies. For example, at one medical center we visited, a recently
             appointed infection control practitioner found out about the network
             only becausea friend at another VA center mentioned it. The practition-
             ers that help with the network are volunteers, and their time comesout
             of either their own program or their personal time. As a result, many of
             the initiatives that are conceivedby the network are delayed or never
             completed.

             Infection control is an important aspect of hospital operations, and per-
Corklusion   sonnel assignedto conduct such programs should be supported by man-
             agement at all levels, The fact that six different units provide guidance
             to infection control practitioners is an indication that the program is not
             well defined or directed by the central office.

             Lack of management attention to a number of areas undercuts the effec-
             tiveness of infection control programs. For example, VA has provided
             limited or no responseto continued requests for (1) a formal mechanism
             to share information, (2) coordination of existing infection control guid-
             ance, and (3) computer support for analysis purposes. This gives a sig-
             nal to the practitioners that their program may not be as important to VA
             as other programs. Moreover, a failure of medical center managementto
             properly recognize infection control as a centerwide effort and a priority
             can hamper the program’s effectiveness. Finally, a shortage of infection
             control staff affects the program’s ability to accomplish its objectives.
             With a minimum of time and money, VA management at the medical
             center, regional, and central office levels can greatly enhanceboth the
             efficiency and effectiveness of infection control programs. Specifically,
             all infection control guidance should be reviewed and coordinated by
             one central unit. This will send a messageto VA staff at all levels that the
             program is important, understood, and well directed. The unit selected
             to perform this function should serve as a mechanism to facilitate com-
             munication between all practitioners in the VA system and should assure
             that developments in the field of infection control, both inside and
             outside VA, are widely disseminated. At the medical centers, directors
             must recognizethat infection control is important to all center staff-
             not just the practitioners -and should, through both words and actions,




             Page 34                                 GAO/IUD-90-27 VA’sInfection Control Programs
                     chrpt%r 9
                     Infectlola confrol Should ReceiveMore
                     Manage&l Attantlon at All VA Levels



 I




                    get this messageout to all staff. The words should indicate strong sup-
                    port; the actions should be the provision of appropriate resourcesto get
                    the job done.

                    We recommend that the Secretary of Veterans Affairs direct the Chief
Recommendations     Medical Director to
                  . designate a single unit in VA’S central office to overseeits infection con-
                    trol programs, including (1) coordinating the central office’s policies and
                    procedures and (2) implementing a mechanism for sharing information
                    among practitioners;
                  . incorporate procedures in regional office survey requirements to assure
                    that each medical center’s infection control program is adequately
                    reviewed; and
                  9 require center directors to reexamine the level of managerial support
                    and resourcesgiven to their infection control programs and to provide
                    additional support where appropriate.

                    In his November 21, 1989, letter, the Secretary of Veterans Affairs con-
Agency Comments     curred with each of our recommendations.The Secretary stated that an
                    office has been designated to overseeVA’S infection control program and
                    this office will work with VA’S infectious diseasefield advisory group in
                    formulating infection control policies and procedures. The regions will
                    work with these program officials to develop appropriate criteria to
                    assessthe programs. The Secretary also stated that the Chief Medical
                    Director will require medical center directors to reexamine their infec-
                    tion control program resourcesand, basedon justifications and sys-
                    temwide priorities, additional support will be provided.




       Y




                    Page 35                                  GAO/klRD90-27 VA’sInfection Cmdrol Programs
Apperdix I

                                                                                           .


             To develop the basic elements, we first consulted with officials of the
             organizations and the individual listed below:
             American Hospital Association.
             Association for Practitioners in Infection Control.
             Centers for DiseaseControl (CDC).
             Joint Commission on Accreditation of Healthcare Organizations.
             The Society of Hospital Epidemiologists of America.
             Robert W, Haley, M.D., who directed CDC'S SENIC study.
             We discussedthe activities they thought were necessaryfor an effective
             infection control program and, working with CDC officials, compiled a
             comprehensive list of elements. The list was sent to the above organiza-
             tions (except CDC) as well as the organizations listed below:
             American Public Health Association.
             The Association of Operating Room Nurses, Inc.
             Association of State and Territorial Health Officials.
             Surgical Infection Society.

             We asked each to indicate which elements could be considered minimum
             requirements for an effective infection control program. From their
             responses,we developed a list of the elements that six or more agreed
             were minimum requirements and subsequently discussedthese with CDC
             infection control experts.

             Using existing Joint Commission standards, published studies demon-
             strating the effectiveness of an element, and CDC’S  judgment as to
             whether the element would be widely supported by infection control
             experts, we arrived at a final list of 56 elements. CDC officials believe
             these elements represent a good basic infection control program.




             Page 36                             GAO/HRD-90-27VA’sInfection Control Programs
   i.
wndix   II

‘I+sic Elementsof an Infection Control


                 The basic elements are divided into five groups: general elements,blood-
                 stream infections, pneumonia, surgical wound infections, and urinary
                 tract infections. The general group includes 14 elements that apply to all
                 hospitals and addressprogram structure, applicable surveillance activi-
                 ties, and control activities. The remaining four groups of elements are
                 organized by the four major types of infection and address surveillance
                 activities (identification, analysis, and reporting) specific to each type.

                 The elements allow for both total and target surveillance. A program
                 performing total surveillance monitors all four major types of infection
                 in every hospital patient on either a periodic or continuous basis. A pro-
                 gram that targets surveillance identifies the areas of highest infection
                 risk or concern and focusesits attention on such areas; for example,
                 patients in the intensive care unit or all bloodstream infections. The spe-
                 cific elements applicable to an infection control program depend on
                 whether the program usestotal 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).
                 Targeted surveillance-the general elements would be used, and,
                 depending on the type(s) of infections being targeted in the high risk
                 groups, other appropriate groups of elements would be used (i.e., blood-
                 stream, pneumonia, surgical wound, or urinary tract).

                 Although the basic elements place emphasis on surveillance activities,
                 an infection control program cannot be effective without control activi-
                 ties. We included in our list only the broad categoriesof control func-
                 tions becausecontrol activities, unlike surveillance activities, are
                 performed not only by the infection control staff but by other hospital
                 personnel. CDC has published detailed recommendations on procedures
                 to be followed by providers to prevent infections. Further, control activ-
                 ities that (1) are carried out by the program and (2) are beneficial to all
                 hospitals are difficult to specify becausethe appropriate control activi-
                 ties depend heavily on the surveillance findings and the circumstances
                 within the individual hospital.
                 The list of elements that follows is not all inclusive, the elements in the
                 tables form a basic rather than an optimal program. Therefore, the ele-
             Y   ments should be used in conjunction with other standards, such as the
                 Joint Commission’s accreditation standards and m-c’s guidelines.



                 Page 37                              GAO/HRD-90-27VA’sInfection Control Programs
                                    AppendbK
                                          rr.                                                                                         I>
                                    Bsele BlentWe of an Infection
                                    Cmtrbl Progrtun                                                                                I,,
                                                                                                                                   km s




Tab1 11.1:CMnenl Element8   (Thew
appl to all hospitala)              structure
                                    Gl*
                                    The hospital has at least a part-time infection control practitioner,
                                    G2.
    t                               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 committee includes representation
                                    from the following:
                                    *hospital administration,
                                    *microbiology laboratory (if one exists),
                                    *medical staff, and
                                    *nursing service.
                                    G5.
                                    The committee meets at least every 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.
                                    G8.
                                    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 aTiV.Q!RFcedures  as they
                                    relate to infection control issues,
                                    GlO.
                                    The hospital’s infection control program assists in developing a
                                    system for reporting infections or infectioTMTf5Bsuresof employees.
                                    Gil.
                                    The hospital’s infection control pro ram assists in identifying and
                                    developing infection control topics Bor orMV3ITBnclasses,
                                    G12.
                                    The hospital’s infection control pro ram assists in identifying and
                                    develoorna infection control topics 9or in-~      trainino.
                                    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.
                                                                                                                     (continued)




                                    Page 38                                      GAO/mm27         VA’sJnfection Control Progrm
                                        Appendix II
                                        Bar4icElement3 of an Infection
                                        Control Program




                                        Control Activities
                                        G14.
                                        Infection control practitioners and registered nurses on hospitals
                                        units have written authority to implement isolation procedures in an
                                        emergency without a physician’s order.


Tal, lo 11.2:Bloodstream   Infections

                                                                                                                  Applicability     to
                                                                                                                surveillance      type
                                        ldentlflcation                                                       Total                    Target
                                        91.                                                                       X                            X
                                        A hospital’s infection control program uses at least one of the
                                        following case-findin approaches to identify bloodstream
                                        infections either in alPpatients or in a subset of patients:
                                        *Review results of blood cultures in all patients in target
                                        population.
                                        *Review all patients’ charts in target population.
                                        +Ieview all patients’ fever charts in target population.
                                        82.                                                                      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 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:
                                        *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).
                                        *Review patients’ charts in target population, identified
                                        through case finding.
                                        Analyslsb
                                        04.                                                                      X                         X
                                        The infection control program has developed initial baseline
                                        rates for hospital-acquired bloodstream infections within the
                                        hospital.
                                        85.                                                                      X                         X
                                        Infection control staff analyze hospital-acquired bloodstream
                                        infection data by pathogen,
                                        B6.                                                                                                X
                                        Infection control staff analyze data on hospital-acquired
                                        bloodstream infections by whether or not patient had
                                        peripheral and/or central IV cannulation.
                                        87.                                                                      X                         X
                                        Infection control staff analyze hospital-acquired bloodstream
                                        infection data by ward.

                     Y




                                        Page 39                                        GAO/IiRD-90-27VA’sInfection Control Programs
                        APpbndix II,
                        Basic Ehmenta    of an   Infection
                        Control Program




                                                                                                  Appllcablllty      to
                                                                                                surveillance       type
                        Reporting                                                            Total                      Target
                        88.                                                                       X                             X
                        Infection control staff report summarized/analyzed data on
                        hospital-acquired bloodstream infections to the infection
                        control committee.
                        59.                                                                                                     X
                        Infection control staff report summarized/analyzed data on
                        hospital-acquired bloodstream infections to the supervisor of
                        the IV therapy team, if one exists.
                        610.                                                                      X                             X
                        Infection control staff report summarized/analyzed data to
                        the ward supervisors or head nurses.


Tablie 11.3:Pneumonia
                                                                                                  Applicability      to
                                                                                                surveillance       type
                        ldentlflcation                                                       Total                     Target
                         Pi.                                                                     X                           X
                        A hospital’s infection control program uses at least one of the
                        followrng case-finding approaches to identify pneumonia
                        either in all patients or in a subset of patients:
                        *Review all patients’ Kardexes in target population.
                        *Ask nurses about signs or symptoms of a respiratory
                        infection in all patients in target population.
                        *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 daysa
                        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).
                        *Review patients’ charts in target population, identified
                        through case finding.
                        Analyslsb
                        P4.                                                                      X
                        The infection control program has developed initial baseline
                        rates for hosoital-acauired pneumonia within the hospital.
                        P5.                    ’     .                                           X                           X
                        Infection control staff analyze data on hospital-acquired
                        pneumonia bv oathoaen.
                        P6.                                                                                                  X
                        Infection control staff analyze data on hospital-acquired
                        pneumonia by whether or not patient was on a ventilator, if
                        target population includes ventilator patients,
                                                                                                                  (continued)



                        Page 40                                        GAO/HRD-90-27VA’sInfection Control Programs
       I
       I

   i                                     Appendix II
                                         Basic Elementa of an Infection
                                         control Program




                                                                                                                   Applicablllty      to
                                                                                                                 surveillance       type
                                         Analysisb                                                            Total                     Target
                                         P7.                                                                       X                             X
                                         Infection control staff analyze data on hospital-acquired
                                         pneumonia by ward.
                                         P8.                                                                      X                           X
                                         Infection control staff analyze data on hospitaLacquired
                                         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
                                         hospital-acquired pneumonia to the infection control
                                         committee.
                                         PlO.                                                                                                 X
                                         If target population includes ventilator patients, infection
                                         control staff report summarized/analyzed data on hospital-
                                         acquired pneumonia to the respiratory therapy department, if
                                         one exists,
                                         Pll.                                                                     X                           X
                                         Infection control staff report summarized/analyzed data on
                                         hospital-acquired pneumonia to the ward supervisors or head
                                         nurses.


Table 11.4:Surgical   Wound Infections
                                                                                                                  Applicability       to
                                                                                                                 swelllance         type
                                         ldentlficatlon                                                       Total                      Target
                                         Si.                                                                      X                            X
                                         A hospital’s infection control program uses at least one of the
                                         following case-findin approaches to identify surgical wound
                                         infections either in alYsurgical patients or in a subset of
                                         surgical patients:
                                         *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,
                                         *Review all surgical patients’ Kardexes in target population.
                                         *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.”
                                                                                                                                   (continued)




                                         Page 41                                      GAO/IiRhftO~27   VA’s   Infection Control Programs
Appendix II
Basic Elements of an Infection
Control Program




                                                                          Applicablllty to
                                                                        surveillance type
ldentlflcatlon                                                       Total                Target
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:
*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).
@Reviewsurgical patients’ charts in target population
identified through case finding.
*Ask 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 surcical wound infections in all patients in
target population-as a case-finding activity). ’
Analysisb
s4.                                                                      X                     X
The infection control program has developed initial baseline
rates for surgical wound Infections in the hospital.
s5.                                                                      X                     X
Infection control staff analyze surgical wound infection data
by surgeon.
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
bv oathoaen.
S8.                                                                      X                     X
Infection control staff analyze surgical wound infection data
bv ward.
Reportina
s9.                                                                      X                     X
Infection control staff report summarized/analyzed data on
surcical 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.




Page 42                                        GAO/HRD-90-27VA’sInfection Control Programs
                                 &we*        Il
                                 Basic Element8 oi an Inrection
                                 Control Program




11.5: Urinary Tract InfectIons
                                                                                                             Appllcablllty    to surveillance
                                                                                                                             type
                                  ldentltlcation                                                                Total                   Target
                                  Ul.                                                                               X                         X
                                  A hospital’s infection control program uses at least one of the
                                  following case-fin&n approaches to identify urinary tract
                                  infections either in al$ patients or in a subset of patients:
                                 *Review all patients’ Kardexes in target population.
                                 *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.
                                 *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 days8
                                 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:
                                 *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).
                                 *Review patients’ charts in target population, identified through
                                 case finding.
                                 Analyslsb
                                 u4.                                                                                X                           X
                                 The infection control program has developed initial baseline
                                 rates for hospital-acquired urinary tract infections within the
                                 hospital.
                                 u5.                                                                                X                           X
                                 Infection control staff analyze data on hospital-acquired urinary
                                 tract infections by pathogen.
                                 U6.                                                                                X                           X
                                 Infection control staff analyze data on hospital-acquired urinary
                                 tract infections by ward.
                                 Repoftlng
                                 u7.                                                                                X                           X
                                 Infection control staff report summarized/analyzed data on
                                 hospital-acquired urinary tract infections to the infection control
                                 committee.
                                 U8.                                                                                X                           X
                                 Infection control staff report summarized/analyzed data on
                                 hospital-acquired urinary tract infections 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 infection rates in specific patient risk
                                 groups, as well as frequency distributions 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 exam.
                                 ple, 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 blood-
                                 stream infections are needed.




                                 Page 43                                              GAO/HRDBO-27VA’sInfection Control Programs
     /
     I


Aphndix III

IbQthodologyfor SamplingNonfederal Hospit&


                                     The sample of nonfederal hospitals for this study was selectedfrom the
                                     1986 listing of American Hospital Association (MIA) memberships. Since
                                     our questionnaire on infection control was not relevant to very small
                                     hospitals, we excluded memberships with fewer than 60 beds before
                                     selecting the sample. Of the 4,411 memberships with 60 or more beds,
                                     we selecteda stratified sample of 660. To insure statistically reliable
                                     estimates for small, medium, and large hospitals, as well as for teaching
                                     and nonteaching hospitals, the sample was selectedfrom five subgroups
                                     (strata) of hospitals (seetable 111.1).
TabId 111.1:Nonfederal Hospitals-
Samble Sizes and Response Rates by                                                                                           Number of
Strati                                                                         1905 AHA             Initial   Adjusted      responses/
                                     Bed rlze/afflllatlon                   memberships           sample       sample0 (response rate)
                                     50-99 beds                                      1,350              110          110           84 (76%)
                                     loo-399 beds/nonteaching                        2,133              110          111           92 (83%)
                                     loo-399 beds/teaching                             376              110          110           95 (86%)
                                     400+ bedsfnonteaching                             141               90          102           93 (91%)
                                     400-k beds/teaching                               411              130          134          116 (87%)
                                     Total                                          4,411              550          567          480 (85%)
                                     aAdjusted sample reflects number of hospitals included in survey after adding extra hospitals identified
                                     as part of a group membership.

                                     Becausewe were aware that a small proportion of AWA memberships
                                     covered more than one hospital, we used the 1986 AHA guide to identify
                                     which of the sampled memberships may have represented multiple hos-
                                     pitals, We then made telephone calls to determine whether those mem-
                                     berships in fact represented more than one hospital and, if so, to obtain
                                     addressesfor each such hospital. As a result of this effort, we discov-
                                     ered in the sample 12 multiple memberships covering 29 hospitals. Con-
                                     sequently, an additional 17 hospitals were added to the sample,
                                     resulting in an adjusted sample of 667 hospitals.
                                     We obtained responsesfrom 86 percent (480 of 667) of the hospitals to
                                     which we mailed questionnaires. Among the sampled subgroups, the
                                     responserate ranged from 76 to 91 percent (seetable 111.1).
                                     While the initial sample of hospital memberships was stratified accord-
                                     ing to the AHA information on total number of beds for the membership,
                                     our results are presented according to the number of acute-carebeds
                                     reported by the hospital. We excluded 37 hospitals that reported having
                                     fewer than 60 acute-carebeds. Consequently, our results are basedon
                                     the 443 hospitals that reported having 60 or more acute-carebeds.


                                     Page 44                                           GAO/HRD-90-27VA’sInfection Control Programs
                                            Since data from 443 hospitals are used to make estimates about the uni-
                                            verse of nonfederal hospitals with 50 or more beds (estimated number is
                                            3,872 hospitals), all data in this report on nonfederal hospitals are sub-
                                            ject to sampling error. The size of the sampling error reflects the preci-
                                            sion of the estimate; the smaller the sampling error, the more precise the
                                            estimate.
                                            Sampling errors for reported estimates about nonfederal hospitals are
                                            presented in table III.2 at the 95-percent confidence level. This means
                                            that the chancesare about 19 out of 20 that the actual number or per-
                                            centagebeing estimated falls within the range defined by our estimate
                                            plus or minus the sampling error.
Table 111.2:Eatlmaks and Correapondlng
San)pllng Error. for Nonfederal Horpltala                                                                            Sam ling error
    !                                                                                                                     !PC-percent
                                                                              Estimated number                     confidence level
                                                                                    of applicable   Percent that
                                            Element                                     hosoltals        comolv
                                            G2.
                                            Trained physician consultant
                                              (50 to 399 bed hospitals)                     3,363             45                    7
                                              (400 or more bed hospitals)                     509             54                    6
                                            G14.
                                            Practitioners and registered
                                            nurses have isolation authority
                                              (100 to 399 bed hospitals)                    2,184             58                    9
                                              (400 or more bed hosdtals)
                                                                  ~I      I
                                                                                              509             55                    6
                                            Bloodstream   infections
                                            82.
                                            Case finding every 3 days                       3,640             83                    5
                                            EM
                                            Baseline rates                                  3,648             63                    6
                                            87.
                                            Analyze data by ward                            3,648             82                    5
                                            B9.
                                            Report data to IV team                            494             57                   17
                                            BIO.
                                            Renort data to ward SuDervisors                 3,648             56                    7
                                            Pneumonia
                                            P2.
                                            Case finding every 3 days                       3,546             60                    7
                                            P4.
                                            Baseline rates                                  3,546             68                    6
                                            P7,
                                            Analyze data by ward                            3,546             83                   5
                                                                                                                         (continued)




                                            Page 46                                   GAO/HRD-90-27VA’sInfection Control Programs
    Appendix III
    Methadology for Sampling
    Nonfederal H~pitala




-
                                                                               Sam ling error
                                                                                    8 5-percent
                                      Estimated number                       confidence level
                                            of a plicable     Percent that
    Element                                     Ii ospitals        comply
    Pneumonia
    PlO.
    Report data to respiratory
    therapv department                                1.054             60                   11
    Pll.”     ’
    Report data to ward supervisors                   3,546             60                    7
    Surgical   wound Infections
    Qr)
    $se finding every 3 days                          3,732             55                    6
    s4.
    Baseline rates                                    3,732             74                   -5
    S5.
    Analyze data by surgeon                           3,732             80                    5
    SlO.
    Report data to surgical
    complications committee                           1,975             62                    8
    s13.
    Practicing surgeons receive
    surgeon-specific data                             3,732             20                    5
    Urinary tract infections
    u2.
    Case finding every 3 days                         3,586             55                    7
    u4.
    Baseline rates                                    3,586             71                    6
    U6.
    Analyze data by ward                              3,586             85                    5
    U80
    Report data to ward supervisors                   3,586             65                    6




    Page 46                                    GAO/IiRIHO-27 VA’sInfection Control Programs
                   Miroed     with a medical        Number of acute-
Medlcal   center                                          care beds
Coatesville, PA    YeS                                           352
Kansas City, MO    Yes                                           315
Lebanon, PA
Memphis, TN        Ye!3                                          55u
New Orleans, LA    Yes                                           327
Portland, OR       No                                            366
Washington, DC     Yes                                           371




Page 47                   GAO/HRD-90-27VA’sInfection Control Program
  I

Apbendix V

v Medical Centers’and Nonfederal Hospitals’
u”,seof GAO’sBasic Elements

                                                                                Nonfederal ho@pltals
                                                    VA centers                        (estimated)
                                                 Number        Percent              Number        Percent
               Barlc element                  applicable         using          applIcablea         using
               General elements:
               Gl.                                    158          100                 3.872           100
               Hospital has an infection
               control Dractitioner
               G2.     ‘-                             158           58                 3.872            46
              Trained physician
              consultant
               G3.                                    158          100                 3.872            99
               Multidisciplinary infection
              control committee
              G4.                                     158           88                 3,872            91
              Appropriate permanent
              committee membership
              G5.                                     158           98                 3,872            94
              Meets at least every 2
              months
              G6.                                     158           99                 3,872            98
              Surveillance for at least one
              of the four major infection
              sites
              G7.                                     158           99                 3,872            97
              Written criteria for
              infections at specific sites
              G8.                                     158           99                 3,872            97
              System to detect and
              control outbreaks of
              infections
               G9.                                    158          100                 3,872           100
              Help to develop hospital
              infection control policies
              and procedures
              GlO:                                    158           99                 3,872            97
              Help to develp a system for
              ;~~~~~mWee

              Gil.                                    158           91                3.872             88
              Help to develop infection
              control topics for
              orientation classes
              G12.                                    158           95                3,872             96
              Help to develop infection
              control tooics for in-service
              training ’
              G13.                                    158           88                3,872             85
              Monitor compliance with
              sDecific patient care
              ljractices
                                                                                               (continued)




              Page 48                                       GAO/HRD-90-27VA’sInfection Control Programe
A~pendlx V
VA Medicnl tinterr’ snd Nonfederal
Hoopitab’ Use of GAO’sBasic Elementa




                                     VA center8
                                  Number        Percent              Number        Percent
Basic element                  applicable         using          applIcablea         using
G14.                                   158           78                3,872             63
Practitioners and registered
nurses have isolation
authority
Bloodstream     Infections:
61.                                    152          100                3,648             99
Appropriate case-finding
aooroach
82.                                    152           83                3,648             83
Case finding every 3 days
83.                                    152           99                3,648            100
Appropriate case-
confirmation approach
84.                                    152           73                3,648             63
Baseline rates
85.                                    152           99                3,648             97
Analvze data bv oathoaen
66.                                     80           90                 1,177            90
Analyze data by whether
patient had IV
B7.                                    152           97                3,648             82
Analyze data by ward
68.                                    152           99                3,648             99
Report data to infection
control committee
B9.                                      9           22                  494             57
Report data to IV team
BlO.                                   152           63                3,648             56
Report data to ward
supervisors
Pneumonia:
Pl.                                    141           88                3,546             93
Appropriate case-finding
aporoach
P2.                                    141           56                3,546             60
Case finding every 3 days
P3.                                    141           98                3,546            100
Appropriate case-
confirmation approach
P4.                                    141           69                3,546             68
Baseline rates
P5.                                    141           98                3,546             97
Analyze data by pathogen
P6.                                     65           86                  976             90
Analyze data by whether or
not patient was on a
ventilator
                                                                                (continued)




Page 49                                      GAO/HRD99-27VA’sInfection Control Programs
-                                                                                     --7
        Appendix V
        VA Medical 6entere’ and Nonfederal
        Hoepitab’ Ueeof GAO%Basic Elements




-
                                                                       Nonfederal hosdtala
                                           VA center8                        (ertlmated~
                                        Number        Percent              Number        Percent
        Baric element                applicable         using          applicable0         urlng
        P7.                                  141           96                 3,546            83
        Analyze data by ward
        P8.                                  122           88                 3.485            93
        Analyze data by whether or
        not patient had surgery
        P9.                                  141           99                 3,546            99
        Report data to infection
        control committee
        PlO.                                  65           46                 1.054            59
        Report data to respiratory
        therapy department
        Pll.                                 141           62                 3,546            60
        Report data to ward
        supervisors
        Burglcal would
        infections:
        Sl.                                  131           95                 3,732            93
        Appropriate case-finding
        approach
        %se finding every 3 days             131           58                 3,732            55

        s3.                                  131           99                 3,732            99
        Appropriate case
        confirmation approach
        s4.                                  131           88                 3,732            74
        Baseline rates
        s5.                                  131           71                 3,732            80
        Analyze infection data by
        surgeon
        S6.                                   71           93                 1,262            91
        po;lyy data by type of

        s7.                                  131           95                 3,732            96
        Analyze data by pathogen
        S8.                                  131           89                 3,732            80
        Analyze data by ward
        s9.                                  131          100                 3,732            99
        Report data to infection
        control committee
        SlO.                                  92           58                 1,975            62
        Report data to surgical
        complications committee
        Sll.                                 131           97                 3,732            80
        Report data to chief of
        surgery
        s12.                                 131           90                 3,732           91
    P
        Report data to operating
        room supervisor
                                                                                      (continued)



        Page 50                                    GAO/HRD-90-27VA’sInfection Control Programs
                                                                                          _ .-
    Appendix V
    VA Medical Centers’ and Nonfixleral
    Hospital& Use of GAO’sBasic Elements




                                              VA center8
                                           Number        Percent                     Number        Percent
    Baric element                       applicable         uring                 applicablea         uring
    s13.                                         131            16                       3,732           20
    Practicing surgeons
    receive surgeon-specific
    infection rates
    Urinary tract infections:
    Ul.                                          141            83                      3,586             90
    Appropriate   case-finding
    approach
    u2.                                          141            53                      3,586             55
    Case finding every 3 days
    u3.                                          141            97                      3,586             98
    Appropriate case-
    confirmation approach
    u4.                                          141            73                      3,586             71
    Baseline rates
    u5.                                          141            99                      3,586             98
    Analyze data by pathogen
    U6.                                          141            99                      3,586             85
    Analyze data by ward
    u7.                                          141            99                      3,586             99
    Report data to infection
    control committee
    U8.                                          141            67                      3,586             65
    Report data to ward
    supervisors
    aThe number of nonfederal hospitals applicable represents an estimate for the universe of all nonfederal
    hospitals, based upon responses to our questionnaire. Sampling errors must be taken into account
    when drawing conclusions from the percentages (see app. 111).  In addition, because VA has a higher
    percentage of large medical centers than the nonfederal sector, caution should be used when compar-
    ing the estimated percentage of all nonfederal hospitals to VA centers using the same elements.




    Page 51                                            GAO/IiRIHO-27 VA’sInf’ection Control Programs



i
   1




Apbendix VI
Qrnrnents From the Department of
V/eterans
 I      Affairs


                                       THE SECRETARY OF VETERANS AFFAIRS
                                                 WASHINGTON




              Mr. Lawrence H. Thompson
              Assistant Comptroller General
              Human Resources Division
              U. S. General Accounting Office
              Waehington, DC 20548
              Dear    Mr. Thompson,
                      am pleased to provide the enclosed detailed comments on your
                      I
              draft  report aON          C-L.   . VA Proarwre          -able      to
                       al prow      But Can Be Enhanced (GAO/HRD-89-1461, dated
              October 6, 1989. The Department is concurring        with each of the
              four recommendations,     and corrective  action   is in process to
              improve our infection   control program.
                      We appreciate   your assistance   in this   matter.


                                                                             .



              Bnclosure




                      Page52
                    lrppencUrrM
                    Csnuneatsl%omthsDepartmentof
                    Veteran6 Affdrm




                                                                                        Enclosure
              DEPARTWENT
                       OF VETERANSAFFAIRS COMMENTS
                                                 ON THE OCTOBER 6, 1989,
                  GAO REPORT aON                     . VA PROCRAMs
                                               CONTROL.
                                                        BUT CAN BE m
%0 Q 27      GAO reOOPrPaOnd8that I require        the Chief Hodioal Dirootor    to update
             VA infeotion    control   guidanoo.      At a minimum, the guidanoo    8hould
             reguiro    oomponants airilar      to tho8e in GAOga bamio l lemonts.
                   We concur w$th the recommendation.      Newly published infection
             control guidance incorporates     GAO’s basic  elements.    This guidance
             will soon be incorporated     into a VA manual chapter.
             QAO al80    rooonmond8     that   I direot   the Chief     Yedioal    Direotor    to:
                   --     De8ignate a 8inglo unit in VA*8 oentral             offioe     to Over8ee
See p
                          itr     infeotion      oontrol       progr8m8,         inoluding       (1)
                          ooordinatingthe      oentral   offioel8    polioie8      an4 prooedures
                          and (2) implementing       a meohanism for 8haring information
                          among praotitioners.
                   We concur with the recommendation.                 The Veterans Health
             Services and Research Administration          Director,     Medical Service       is
             designated     as the central      focus for overseeing         VA's infection
             control   program.      He will   work in concert with the Infectious
             Disease Field Advisory Group in fomulating            policies    and procedures
             for the Departments's infection         control program.
See p. 35.         a-    Inaorporate      proaedure8     in    regional     offiaa8     survey
                         requirement8      to asnure      that    l aoh    medical    aenter's
                         infeotion    oontrol  program ir adequately reviewed.
                   We concur with the recommendation.       The regions will assure
             that each medical center's infection    control program is adequately
             reviewed and will work with the infection    control program officials
             in VA Central Office  to develop appropriate      review criteria.
See p. 35.         am    Require     aenter    direotor8     to reeramine the level       of
                         managerial     nupport and re8ouroe8 given to their    infection
                         control    program8   and to provide    additional WAgpOrt where
                         appropriate.

                    We concur with the recommendation. The Chief Medical Director
             will require his medical center directors      to reexamine resources
             allocated to their infection    control programs. Additional   support
             for these programs will     be provided  based on justified  need and
             systemwide priorities.




                    Pagelt
     Ap&ndix VII                                                                                                          ,
     Major Contributors to This Report
                                                                                                                              P




                                    James A. Carlan, Assistant Director
    HqknanResources                 Michelle L. Roman, Assignment Manager
    Dibision,                       Mary Ann Curran, Evaluator
    Wdshin&on, DC.
      I
                                    Randall B. Williamson, Regional ManagementRepresentative
        tle Regional Office         Walter R. Eichner, Evaluator-in-Charge
          /                         Lori D. Pang, Evaluator
          I                         SusanK. Hoffman, Evaluator


:   optional       Security   and   Michael J. Morgan, Evaluator

1 International Affairs
  Dikision




    (101321)                        Page 64                        GAO/IiRD-90-27   VA’s Infection   Control   Programs
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