oversight

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

Published by the Government Accountability Office on 1990-04-27.

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

                mtw     fi-@rms &e
                Comparableto VA and
                Nonfederal Programs
                but Can Be Enhanced




GAQ’HRD-90-74
                 1

n
    P   -’   c
United States
General Accounting  Office
Washington, D.C. 20548

Human Resources Division

B-232863

April   27,199O

The Honorable Daniel K. Inouye
United States Senate

The Honorable Claiborne Pell
United States Senate

The Honorable Jim Sasser
United States Senate

In response to your request, this report discusses infection control programs in military
hospitals and compares them to similar efforts in Department of Veterans Affairs (VA) and
nonfederal hospitals.

We found that military infection control programs are comparable to those in VA and the
nonfederal sector in the extent to which they use the infection control program elements that
we identified in conjunction with acknowledged infection control experts. In fact, military
programs are using more of these elements than are required in service regulations.
However, these programs need more support from hospital management and more technical
assistance from the services.

Several recommendations are made to improve these programs, all of which the Department
of Defense agrees with.

As arranged with your offices, we are sending copies of this report to the Secretary of
Defense, appropriate congressional committees, and other interested parties.

The report was prepared under the direction of David P. Baine, Director, Federal Health Care
Delivery Issues, who can be reached on (202) 275-6207 if you have any questions. Other
major contributors are listed in appendix VIII.




Lawrence H. Thompson
Assistant Comptroller General
                                                                                        --
Executive Summ~


Purpose      all patients who enter a hospital contract at least one infection during
             their stay. With over 800,000 inpatient admissions annually, some
             40,000 patients could contract infections each year while being treated
             in military hospitals. The incidence of hospital-acquired infections can
             be reduced, however, if hospitals operate effective programs to control
             infections.

             Therefore, in line with their continuing interest in the quality of care in
             military hospitals, Senators lnouye, Pell, and Sasser requested GAO to
             review infection control programs in those hospitals. In performing this
             review, GAO assessed the completeness and adequacy of military infec-
             tion control programs and compared those programs with programs
             operated in similar-sized Department of Veterans Affairs (VA) and
             nonfederal hospitals.


             The Office of the Assistant Secretary of Defense for Health Affairs has
Background   delegated responsibility for developing and implementing infection con-
             trol policies and procedures to the three services (the Army, Navy, and
             Air Force) that operate hospitals. The services require their hospitals to
             operate infection control programs to identify existing infections and
             help prevent future occurrences.

             GAO needed criteria outlining the basic elements of an effective infection
             control program in order to assess the programs operating in military
             hospitals. The program guidance the Department of Defense (DOD) and
             the three services issued to hospitals was too broad to serve this pur-
             pose. Moreover, no other U.S. health care organization had up-to-date
             and specific guidance.

             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 56 basic elements of an effective program.
             The nine organizations included CDC,the Joint Commission on Accredita-
             tion of Healthcare Organizations, the American Hospital Association, the
             Association for Practitioners in Infection Control, and the Society of
             Hospital Epidemiologists of America. (See app. I.)

             These elements, referred to in this report as GAO'S basic elements, are
             applicable to infection control programs in any hospital with over 50
             acute-care beds. (See app. II.)



             Page 2                                      GAO/HRD90-74DOD Infection Control
-.
                            Exomtivr Sumrnar~




                            GAO used these elements to examine military hospital infection control
                            programs. It collected information through visits to nine military hospi-
                            tals and a questionnaire sent to all 79 military hospitals with more than
                            50 acute-care beds, all ~1 medical centers, and a sample of 567
                            nonfederal hospitals. GAOused the questionnaire responses to compare
                            military infection control programs with those in VA and nonfederal
                            hospitals.


                            Service guidelines do not include most of GAO'S elements. However,
Results in Brief            infection control practitioners in military hospitals are using most of the
                            elements. In the military hospitals GAO visited, the elements were used
                            largely because of the individual initiative of the infection control prac-
                            titioners. Having only limited guidance and direction from the services,
                            military practitioners sought current infection control information and
                            implemented many activities that went beyond their guidance and
                            included the basic elements. The extent of use by military hospitals was
                            similar to that of VAand nonfederal hospitals.

                            Several of the basic infection control elements, however, should be used
                            by more practitioners in both the public and private sectors. These ele-
                            ments are generally more labor intensive than those in widespread use.

                            In addition, to be most effective, military infection control programs
                            need management attention. The programs generally (1) lacked
                            resources to perform all of c;no’s basic elements or, in some cases,
                            service-required activities; (2) were a low priority with hospital man-
                            agement; and (3) were not adequately monitored by the services.



Principal Findings

Service Infection Control   Service guidance on infection control programs requires the use of few
Guidance Needs to Be        of GAO'S elements. Of the 56 elements GAO believes should be basic to
                            infection control programs, Air Force instructions specify 31; Navy
Updated                     instructions, 13; and Army instructions, 10. At the nine hospitals GAO
                            reviewed, 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 service instructions and included most of GAO's basic elements.
                            (See p. 20.)


                            Pagr 3                                      GAO/HRDSO-74DDD Infection Control
                         Executive Summary




                         Fifteen of the elements GAO identified are not being used as frequently
                         by the military hospitals as the other 41. These elements, not one of
                         which is included in service instructions, include assuring that physician
                         advisors have taken a course in hospital infection control programs,
                         more frequently conducting activities that identify infections, routinely
                         reporting surgical wound infection rates to practicing surgeons, and
                         reporting ward-specific infection data to ward supervisors. (See
                         pp. 2 l-27.)


Military Programs        Military infection control programs are comparable to those of VA medi-
Comparable to VA and     cal centers and nonfederal hospitals in the extent to which they are
                         using the GAO elements. Military hospitals generally use 41 of the 56
NOI Ifederal Programs    basic elements, while VA medical centers use 44 and nonfederal hospi-
                         tals, 42. With the exception of one area, the specific elements used are
                         the same and the utilization rates are similar. The specific elements that
                         are being used less by military hospitals are also being used less in VA
                         medical centers and nonfederal hospitals and, again, the utilization rates
                         are similar. (See pp. 20-21.)


Management Issues Must   Programs at six of the nine hospitals GAO visited lacked sufficient
Be Resolved              resources (a combination of practitioners, administrative support, and
                         computer-related support) to accomplish necessary infection control
                         activities. For example, at one hospital, the practitioner collected infor-
                         mation about infections, but did not analyze the information because she
                         did not have time and lacked a computer program that would facilitate
                         analysis. These factors reduced the programs’ effectiveness, and may
                         have lessened hospitals’ ability to prevent infections. (See pp. 31-34.)

                         The services’ mid-level commands are responsible for monitoring mili-
                         tary hospital infection control programs. Service mid-level commands
                         review hospitals’ infection control programs only when requested by the
                         hospital. The services said they rely on inspector general reports to
                         identify weaknesses in infection control programs. However, we found
                         inspector general teams lack specific guidance and trained staff to thor-
                         oughly assess infection control programs, and their reports did not iden-
                         tify existing weaknesses. (See pp. 34-36.)




                         Page 4                                     GAO,‘HRLMO-74DOD Infection Control
-
                      Executive Summary




                      GAO recommends that the Secretary of Defense direct the service secre-
Recommendations       taries, in conjunction with the Assistant Secretary for Health Affairs, to

                  . update service guidance to include components similar to GAO'S basic ele-
                    ments (see p. 28),
                  . require the surgeons general to determine the relative priority of the
                    infection control programs in relation to other hospital activities and
                    ensure that hospitals provide additional resources for infection control
                    where appropriate, and
                  . ensure that headquarters or mid-level command staff who are familiar
                    with infection control program activities schedule periodic visits to pro-
                    vide technical assistance to each hospital’s infection control program
                    (see pp. 36-37).


                      In its March 28, 1990, letter, DOD concurred with our findings and recom-
Agency Comments       mendations and stated that by May 1990 it will direct the services to:

                  l   Adopt infection control policies that reflect the intent of the GAO ele-
                      ments and are in compliance with the standards of the Joint Commis-
                      sion, those of other nationally recognized experts, or both, as
                      appropriate. The policies should describe the level of support required
                      for the program.
                  l   Reemphasize the importance of infection control programs to quality
                      patient outcomes.
                  l   Review infection control programs and assets, relative to resources, and
                      take corrective action, as appropriate.
                  l   Provide for both technical assistance and regular evaluation of the full
                      scope of hospital infection control programs.

                      DOD also stated that it will continue efforts tq facilitate and improve pro-
                      gram management practices through the implementation and refinement
                      of automated systems.




                      Page 6                                      GAO/HRD-90-74DODInfection Control
                                                                                                   ,--

contents


Executive Summary                                                                                    2
                       A
Chapter 1                                                                                           10
IntrGduction               Importance of Infection Control Programs                                 10
                           Military Infection Control Programs                                      11
                           Costs of Hospital-Acquired Infections
                           Objectives, Scope, and Methodology

Chapter 2
Increased Usage of         Basic Elements of an Infection Control Program                           17
                           Military Practitioners Utilize Many Basic Elements on                    20
Our Basic Elements               Their Own Initiative
Could Improve              Some Basic Elements Are Not as Widely Used as Others                     21
                           Military and VA Use of One Element Differs Significantly                 27
Infection Control                From Nonfederal Sector
Programs                   Army and Air Force Consultants Support Use of Our                        28
                                 Elements
                           Conclusions                                                              28
                           Recommendation                                                           28
                           Agency Comments                                                          29

Chapter 3                                                                                           30
Infection Control          Hospital Management Does Not Emphasize Infection                         30
                               Control
Should Receive More        Command Monitoring of Infection Control Programs Is                      34
Managerial Attention           Inadequate
at All DOD Levels          Conclusions                                                              36
                           Recommendations                                                          36
                           Agency Comments                                                          37

Appendixes                 Appendix I: Methodology Used to Develop the Basic                        38
                               Elements of an Infection Control Program
                           Appendix II: Basic Elements of an Infection Control                      39
                               Program
                           Appendix III: Methodology for Sampling Nonfederal
                               Hospitals
                           Appendix IV: Military Hospitals Visited
                           Appendix V: Military and Nonfederal Hospitals’ Use of
                               GAO’s Basic Elements




                           Page 6                                     GAO/HRD-90-74DOD Infection Co&r01
         Contents




         Appendix VI: Military Hospitals’ Use of Selected Infection                58
             Control Basic Elements
         Appendix VII: Comments From the Department of                             61
             Defense
         Appendix VIII: Major Contributors to This Report                          74

Tables   Table 2.1: Hospitals That Do Not Have Physician                           22
              Consultant/Supervisor Trained in Infection Control
         Table 2.2: Hospitals Not Performing Case Finding at Least                 23
             Every 3 Days
         Table 2.3: Hospitals Conducting Surveillance That Do Not                  25
              Have Baseline Rates
         Table 2.4: Hospitals Analyzing Infections, but Not                        26
              Reporting Results to Appropriate Personnel
         Table II. 1: General Elements (These Apply to All                         40
              Hospitals)
         Table 11.2:Bloodstream Infections                                         41
         Table 11.3:Pneumonia                                                      43
         Table 11.4:Surgical Wound Infections                                      45
         Table II.5: Urinary Tract Infections                                      47
         Table 111.1:Nonfederal Hospitals- Sample Sizes and                        49
              Response Rates by Strata
         Table III.2: Estimates and Corresponding Sampling Errors                  51
              for Nonfederal Hospitals
         Table VI. 1: Hospitals That Do Not Have Physician                         58
             Consultants/Supervisors Trained in Infection Control
         Table VI.2: Hospitals Not Performing Case Finding at                      58
             Least Every 3 Days
         Table VI.3: Hospitals Conducting Surveillance That Do                     59
             Not Have Baseline Rates
         Table VI.4: Hospitals Analyzing Infections, but Not                       60
             Reporting Results to Appropriate Personnel

Figure   Figure 2.1: Main Categories of Elements in Infection                      19
              Control Programs




         Page 7                                     GAO/~90-74   DOD Infection Control
Cmtents




Abbreviations
AHA       American Hospital Association
CDC       Centers for Disease Control
DOD       Department of Defense
GAO       General Accounting Office
IV        Intravenous
SENlC     Study on the Efficacy of Nosocomial Infection Control
VA        Department of Veterans Affairs


Page8                                     GAO/HRB90-74 DOD Infwtion Control
Page 9   GAO/HRD-90-74WD Infection Control
Chapter 1

Introduction


                    Hospital-acquired infections are a significant health concern in the
                    United States. The Centers for Disease Control (CDC) estimates that
                    about 5 percent of all inpatients contract at least one hospital-acquired
                    infection during their hospital stay. In 1987, the Department of Defense
                    (DOD), through the three armed services, admitted over 800,000 patients
                    to its 168 hospitals. A 5-percent rate of infection would suggest that
                    40,000 of these patients could have acquired infections-some of which
                    could have been life threatening. But the number of infections can be
                    reduced through effective hospital infection control programs. There-
                    fore, in line with their continuing interest in the quality of care in mili-
                    tary hospitals, Senators Inouye, Pell, and Sasser requested us to review
                    infection control programs in those hospitals. In performing this review,
                    we assessed the completeness and adequacy of military infection control
                    programs and compared those programs with programs operated in
                    similar-sized Department of Veterans Affairs (VA) and nonfederal
                    hospitals.


                    Many factors contribute to the prevalence of hospital-acquired infec-
Importance of       tions, Hospitalized patients tend to be more susceptible to infection than
Infection Control   healthy individuals because they are often ill or injured when they enter
Programs            the hospital. Others may become susceptible as a result of surgery,
                    insertion of catheters or tubes, or through the use of other equipment
                    related to hospital care, such as ventilators. Further, patients admitted
                    with infections could expose other patients to those infections. Visitors
                    and hospital staff also introduce disease-causing organisms. However,
                    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 as simple as washing their hands before and after
                    providing care to each patient or using the proper technique to insert a
                    needle intravenously.

                    In order to minimize the incidence of infections, hospital infection con-
                    trol programs monitor and emphasize patient care practices through two
                    interrelated activities-surveillance    and control. Surveillance activities
                    involve (1) identifying patients with hospital-acquired infections, (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 weaknesses in their patient care
                    practices. Control activities consist of the specific actions taken to pre-
                    vent infections, such as developing and revising hospital policies; teach-
                    ing and reinforcing proper patient care practices; and implementing
                    certain practices, such as the isolation of infected patients.


                    Page 10                                     GAO/HRD-SO-74
                                                                            DOD Infection Control
                     Chapter 1
                     Introduction




                     In 1974, CDC began a major study of infection control programs in hospi-
                     tals.’ In that study, hospitals without infection control programs were
                     compared with hospitals that had such programs+ The results of this
                     effort showed that when an effective program was instituted, hospital-
                     acquired infections could be significantly reduced. The study, which was
                     updated in 1983, covered the four major types of hospital-acquired
                     infections: bloodstream, pneumonia, surgical wound, and urinary tract.
                     Officials conducting the study estimated that such infections constitute
                     more than 80 percent of all hospital-acquired infections. CDCofficials
                     informed us that, generally, the findings of this study are as pertinent
                     today as they were in 1974 and 1983. Specifically, if a hospital imple-
                     ments an effective infection control program, it will decrease its
                     hospital-acquired infection rate.


                     The Office of the Assistant Secretary of Defense for Health Affairs has
Military Infection   delegated responsibility for the development and implementation of pol-
Control Programs     icies and procedures related to infection control to the three services
                     (the Army, Navy, and Air Force). Further, the Assistant Secretary’s
                     Office has directed that all military hospitals with more than 25 beds be
                     accredited by the Joint Commission on Accreditation of Healthcare
                     Organizations. The Joint Commission establishes accreditation stan-
                     dards for both federal and nonfederal hospitals and requires, among
                     other things, that hospitals maintain infection control programs.2
                     Approximately every 1 to 2 years, inspectors general assigned to service
                     headquarters (Air Force) or to a mid-level command (Army and Navy)3
                     review hospitals’ compliance with Joint Commission standards, includ-
                     ing those related to infection control.

                     The services operate 168 hospitals worldwide, which, in 1987, admitted
                     839,886 patients. These hospitals vary in size from fewer than IO to
                     over 900 patient beds. Each service has a surgeon general who exercises

                     ’ CDC’s “Study of the Efficacy of Nosocomial Infection Control” (SENIC) evaluated the impact of
                     surveillance and control activities on hospital-acquired infections in a sample of hospitals.
                     “For example, Joint Commission revised standards, which took effect on January 1, 1990, require
                     hospitals to have effective programs for the surveillance, prevention, and control of infections and
                     that all hospital departments have written policies and procedures for infection control.

                     “Organizational units between the service level and hospital level are referred to as mid-level com-
                     mands. The Air Force has 12 mission-oriented commands that include the Tactical Air Command, the
                     Military Airlift Command, and others; the Navy has six Health Service Support Offices that corre
                     spend to the fleet commands; and the Army has three geographic commands, including the Health
                     Services Command, which is responsible for the continental United States. In addition, the Health
                     Services Command contains eight Army medical centers that provide oversight and technical as.&-
                     tance for the smaller facilities within their regions.



                     Page 11                                                     GAO/HRD-90-74DOD Infection Control
                                                                                          L

Chapter 1
tntroduction




technical supervision over its health care facilities. The surgeons general
issue infection control policies and regulations through one or more staff
offices under their authority, either quality assurance (Air Force) or
both quality assurance and preventive medicine offices (Army and
Navy). The Army revised its two regulations governing infection control
programs in August 1986 and April 1987. These regulations are general
in nature and generally limited to the program structure (program
organization and responsibilities). In April 1988, the Air Force issued a
draft infection control regulation4 that includes general requirements
similar to the Army requirements and also (1) details required patient
care practices, (2) elaborates upon staff duties, and (3) provides detailed
criteria describing under what circumstances an infection should be con-
sidered as hospital acquired. In January 1989, the Navy issued two
infection control manuals (one for hospitals and one for clinics) that
provide standardized guidance for Navy hospital infection control pro-
grams, such as suggested surveillance, analysis, and reporting activities.
As of November 1989, the Navy was writing an infection control regula-
tion to supplement its existing quality assurance regulation.

30th the Air Force and the Army have designated specific officers as
infection control consultants who provide assistance to the hospitals
when requested. In January 1989, the Navy designated the practitioners
at the four largest Navy hospitals and the Chief of the Naval Environ-
mental Health Department as Navy infection control consultants who
will be available to provide advice and consultation to Navy practition-
ers throughout the service. As of October 1989, Navy quality assurance
staff from mid-level commands were required to visit hospitals annu-
ally. In March 1990, DOD officials informed us this is no longer required
and that the newly established Health Service Support Offices will have
quality assurance officers available for consultation.

Information about any serious infection control problems found during
inspector general reviews, mid-level command reviews, or Joint Commis-
sion accreditation surveys is provided to the surgeons general by the
performing organization. The surgeons general do not require hospitals
to submit any extensive infection control information. Service hospitals
do, however, report overall infection rates in their annual quality assur-
ance reports.

Within each service’s hospitals (1) commanders are responsible for
establishing and maintaining effective infection control programs,

“The final version of this regulation became effective August 1, 1989.



Page 12                                                    GAO/HRD90-14 DOD Infection Control
                         Chapter 1
                         Introduction




                         (2) infection control committee chairmen are assigned responsibility for
                         directing the program’s operations, and (3) infection control practition-
                         ers have primary responsibility for implementing the hospital’s infection
                         control program.


Costs of Hospital-       less illnesses, untimely death, and additional costs for treatment (e.g,,
Acquired Infections      unplanned surgery or intravenous antibiotics). According to research
                         based on the SENIC study, each hospital-acquired infection adds an aver-
                         age of 4 days to a patient’s hospital stay, with associated costs. These
                         findings apply directly to military hospitals, which in many circum-
                         stances lack sufficient staff or other resources to serve additional
                         patients. Specifically, if patients are required to extend their stays
                         because of hospital-acquired infections, other potential patients may
                         have to be referred to more expensive, nonfederal facilities, thus
                         increasing DOD’S medical costs,

                         Increased costs are not the only result of hospital-acquired infections;
                         the patients may also suffer discomfort or, in extreme cases, permanent
                         harm. The “costs” to the patient who has an infection vary. For exam-
                         ple, urinary tract infections can be painful, but are generally not life
                         threatening, whereas pneumonia and bloodstream infections could be
                         fatal if not detected and treated in a timely manner.


                         The objective of our review was to (1) evaluate the content of military
Objectives, Scope, and   infection control programs and the level of support such programs
Methodology              received from administration at all levels, and (2) determine how these
                         programs compared with those in nonfederal hospitals. Because we also
                         had data on VA’S medical centers,” we incorporated information on their
                         programs for comparative purposes. We conducted this evaluation dur-
                         ing the period November 1987 to November 1989, in accordance with
                         generally accepted government auditing standards.

                         Before starting this review, we met several times with CDCofficials to
                         discuss, from a conceptual perspective, what a good basic infection con-
                         trol program should consist of (i.e., a program that would consist only of
                         fundamentals). Drawing from these discussions, we determined that
                         there was no current, generally accepted written guidance available to

                         “Infection Control: VA Programs Are Comparable to Nonfederal Programs, but Can Be Enhanced
                         (cAO/HRD-90-27, .Jan. 31, 1990).



                         Page 13                                                GAO/IIR.D~74 DOD Infection Control
Chapter 1
Introduction




the health care community on what constitutes the basic elements of an
effective surveillance program.” Given this lack of guidance, we sought
out eight additional organizations that are recognized by the medical
community as having expertise in infection control, and one infection
control expert, to develop a comprehensive list of elements that might
be included in a basic infection control program in today’s medical envi-
ronment. Appendix I describes how the basic elements were developed
and lists 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, which we believe represent the fundamentals of an effective
infection control program (see app. 11).The basic elements place empha-
sis on surveillance activities; however, control activities are vital to an
infection control program. We included in our list only broad categories
of control activities performed by infection control staff because some
control activities, unlike surveillance activities, are performed not only
by the infection control staff but by other hospital personnel. Further,
the control activities performed by the infection control staff depend
heavily on the surveillance findings and circumstances within the hospi-
tal. The basic elements are limited to those appropriate for acute-care
hospitals with more than 50 beds because infection control experts
informed us that infection control needs and practices differ for hospi-
tals providing long-term care and for hospitals with fewer than 50 beds.
The elements were used to examine the content of military infection con-
trol programs and compare them with VA and nonfederal programs.

To help (1) evaluate the content of military infection control programs
being conducted in calendar year 1987 and (2) compare the content of
military programs with VA and nonfederal programs, we prepared a
questionnaire in conjunction with CDC that was based on the basic ele-
ments we developed. In May 1988, we sent the questionnaire to all 79
military hospitals with more than 50 beds, 159 VA medical centers, and a
random sample of 567 nonfederal hospitais stratified by size and affilia-
tion. Usable responses were received from 77 military and 443
nonfederal hospitals and 158 VA medical centers. The data from the 443
nonfederal hospitals were used to make estimates about the universe of
nonfederal hospitals with 50 or more acute care beds (estimated at
3,872). All of the data on nonfederal hospitals in this report are based

“Guidance on infection surveillance programs should be differentiated from guidance on patient care
practices related to infection control. CDC guidelines detail recommendations on practices to be car-
ried out by providers to prevent infections, but specific guidance on surveillance procedures was not
available.



Page 14                                                    GAO/HRD90-74 DOD infection Control
         Chapter 1
         Introduction




         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 associated with the estimates for the nonfederal
         hospitals.

        To encourage respondents to answer the questionnaire accurately, we
        promised them confidentiality. A random sample of 16 military hospi-
        tals was requested to submit certain documentation that would allow us
        to verify their responses to nine of the questions. Twelve of the 16 hos-
        pitals submitted documentation that verified their responses to those
        nine questions.7

        We visited 9 hospitals-3 from each service-from the 79 military hos-
        pitals with more than 50 operating beds. The nine were judgmentally
        selected to provide a variety of hospital size and geographic location.
        The results from these nine hospitals cannot be projected to the military
        services as a whole. The nine military hospitals we visited are listed in
        appendix IV.

        At each of the nine hospitals we examined their infection control pro-
        grams by:

    l   interviewing the commanding officer, the infection control committee
        chair, the infection control practitioner, and other physicians, nurses,
        and administrative staff;
l       reviewing minutes of the infection control committee and the quality
        assurance committee and other documentation;
l       examining data on infections; and
l       accompanying infection control practitioners on ward rounds.

        To allow comparison of the questionnaire results between military hos-
        pitals, VA medical centers, and nonfederal hospitals, we divided the hos-
        pitals into three groups according to bed size (50-99 beds, loo-399 beds,
        and 400 or more beds). Our conclusions were the same regardless of
        whether or not we compared responses from military, VA, and
        nonfederal hospitals by size. Therefore, in this report, we included the
        results from all hospital responses without regard to size.




        ‘The remaining four hospitals were contacted by telephone about supplying dowmentation, but they
        did not provide any.



        Page 15                                                 GAO/HRD-90-74DOD Infection Control
                                                                                                        .-
Chapter 1
Introduction




Our comparison of infection control programs focused on the extent to
which the military, VA, and nonfederal programs were utilizing the ele-
ments we identified. We did not attempt to calculate or compare infec-
tion rates for the hospitals in these sectors.

We met with officials and gathered documentation from DOD and ser-
vices’ headquarters and mid-level commands about the oversight, guid-
ance, and technical assistance they provide the hospitals on infection
control. Major offices visited included the Office of the Assistant Secre-
tary of Defense for Health Affairs; the Army, Navy, and Air Force
Offices of the Surgeons General; the Army Health Services Command;
the Navy Medical Command; the Air Force Tactical Air Command and
Air Training Command; and the Navy Southwest and National Capital
Regional Offices. We also reviewed 1987 and 1988 Inspector General
reports for Army and Air Force hospitals, and Navy reports for medical
geographic commands and hospitals in our sample. Finally, we discussed
the development and importance of our basic elements with Army and
Air Force infection control expertsx




‘At the time of our review, the Navy had not designated any individuals as infection control experts.



Page 16                                                     GAO/I-IRIS9074 DODInfection Control
shapter 2

Increased Usage of Our Basic Elements Could
Improve Infection Control Programs

                       The 56 elements we identified have applicability to military hospitals, VA
                       medical centers, and nonfederal hospitals. Each of these groups is cur-
                       rently using a significant number of these elements, and the utilization
                       rates for specific elements are similar. (See app. V for utilization rates
                       by military and nonfederal hospitals.) Military infection control staff
                       are generally using 41 of the 56 basic elements we developed, practition-
                       ers in VA are using 44, and practitioners in the nonfederal sector are
                       using 42. The three services’ regulations require or provide for between
                       10 and 31 of these elements.

                       The elements that were not generally used by practitioners in military
                       hospitals, VA medical centers, or nonfederal hospitals included: reporting
                       infections to ward supervisors and surgeons; performing, at required
                       frequency, identification activities for surgical wound infections, uri-
                       nary tract infections, and pneumonia; and developing baseline infection
                       rates. Failure to use these elements hampers the effectiveness of an
                       infection control program.


                       Prior to beginning this review, we found no detailed DODguidance on
Basic Elements of an   infection control. Further, the guidance on infection control programs
Infection Control      that existed in the health care community, in general, either was out-
Program                dated, did not cover all the major components of a program, or was not
                       specific as to what the basic elements of a program were. For example,
                       the Joint Commission on Accreditation of Healthcare Organizations was
                       in the process of rewriting its standards on infection control programs.1
                       Researchers had published studies showing the effectiveness of individ-
                       ual program activities in reducing the number of infections, but no one
                       had studied an overall program since CDC’SStudy of the Efficacy of
                       Kosocomial Infection Control (SENC). Also, an American Hospital Associ-
                       ation infection control handbook listed 15 surveillance and control activ-
                       ities and stated that some or all of them may be performed by the
                       infection control practitioner. The handbook did not differentiate
                       between activities that should be performed for a basic program and
                       activities that go beyond a basic program and are part of an optimal
                       program,

                       As discussed in chapter 1, to fairly evaluate the content of military
                       infection control programs, we worked with several organizations
                       knowledgeable in infection control to identify a set of current basic ele-
                       ments that are flexible enough to apply to different, acute-care hospital

                       ‘The revised standards on infccrion control took effect on hIWdq   1, 1990.



                       Page 17                                                      GAO/HR.D-90-74DOD Infection Control
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    chapter 2
    Increased Usageof Our Basic Elements Could
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    environments.” The result is a set of 56 elements in five categories: gen-
    eral elements, bloodstream infections, pneumonia, surgical wound infec-
    tions, and urinary tract infections. Appendix II contains a complete
    listing of these elements. The general elements category includes 14 ele-
    ments that would apply to all hospitals and addresses the structure of
    the program and surveillance and control activities. The remaining four
    categories represent surveillance activities specific to the major types of
    infections. The surveillance activities relate to:

9 identification of infections, what sources to use and how often to iden-
  tify infections;
9 analysis of infections, what factors should be analyzed to determine the
  causes of an infection; and
l reporting of infections, which hospital officials should receive analyzed
  infection data.

    Figure 2.1 cites specific examples of the elements that are included in
    each group.




    ‘Hospital environments may differ in the types of clinicaJ services offered, the types and amount of
    available resources, and the number and risk of infections.



    Page 18                                                    GAO/HRD-90-74DOD Infection Control
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                                          hyenaed Usageof Our Basic Elements Could
                                          Impmve Infection Cbntml prolpm




Figure 2.1: Main Categories of Elements
in Infection Control Programs
                                          Category                                    Examples         of Basic Elements

                                          I                                 i         I                                                                       1
                                                                                          l       The infection control     committee   meets at least
                                               General   (14 elements)
                                                                                                  every 2 months.
                                                                                          l       The hospital’s infection control program has
                                                                                  i               written standardized     criteria (definitions) for
                                                                                                  hospital-acquired    infections it specific sites.          I
                                                                                          l       The hospital’s infection control program assists in
                                                                                                  identifying  and developing topics for in-service
                                                                                                  training.




                                                                                          Identification
                                          [-                                              .       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
                                                                                                  l   review of patients’   charts
                                                                                                  l   review of patients’   fever charts




                                                                                                  control   program    performs an acceptable case-
                                                                                                  finding   approach    on an average of every 3 days.



                                                                                          Analysis
                                                                                          l  The infection control staff analyzes            surgical
                                                                                             wound infection data by surgeon.



                                               Urinary Tract Infection                    Reporting
                                               Surveillance  (8 elements)                     l   The infection control staff reports ward-specific
                                                                                                  summarized/analyzed      data on hospital-acquired
                                                                                                  urinary tract infections to the ward supervisors       or
                                                                                                  head nurses.
                                                                                --i



                                          Our basic elements allow for two different surveillance approaches:
                                          total surveillance or targeted surveillance. Under total surveillance, an
                                          infection control practitioner searches for all four types of infection in
                                          every hospital patient, on either a periodic or continuous basis. Practi-
                                          tioners performing this type of surveillance would generally use 51 of




                                          Page 19                                                               GAO/HRlMO-74 DOD Infection Control
                         chapter2
                         Increased Usageof Our Basic Elements Could
                         Improve Infection Control Pmgranw




                         our 56 elements3 Under targeted surveillance, the areas of highest risk
                         or concern are periodically identified, and the infection control practi-
                         tioner focuses his or her attention on those areas. Under this type of
                         surveillance, 14 general elements would always apply, and the remain-
                         ing elements used would depend on the specific areas of concern being
                         targeted: bloodstream, pneumonia, surgical wound, or urinary tract.
                         Further, for a specific period of time, a hospital may also elect to search
                         for one or more of the infection types in only high-risk patients, such as
                         patients in the intensive care unit,

                         The type of surveillance a hospital used depends on the staff available
                         and the special requirements or interests of the hospital. CDCofficials
                         stated that, in the 197Os, medical authorities believed that all hospitals
                         should conduct total surveillance. Since that time, experts have
                         acknowledged that infection control program resources are 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 considered an acceptable
                         approach.

                         The number of elements applicable to a hospital’s program depends
                         upon the surveillance approach.


                         Our analysis of questionnaire responses indicated that 41 of the 56 basic
Military Practitioners   elements were being used by at least 70 percent of military hospitals
Utilize Many Basic       when such use was appropriate.4 The other elements were also used by
Elements on Their        hospitals in each group, but to a more limited extent. Given that the
                         services’ guidance on infection control programs neither require nor
Own Initiative           address all of our elements (the Air Force requires 31; the Navy, 13, and
                         the Army, lo), this utilization rate is excellent and is largely attributable
                         to the professionalism of the practitioners. For example, practitioners at
                         the nine hospitals we visited took the initiative to take training, contact
                         others, or read literature on infection control programs. As a result,,
                         some activities in their programs went beyond service guidance and
                         included many of our basic elements. Similarly, 44 elements were used
                         by at least 70 percent of applicable VA medical centers, and 42 elements

                         3The five remaining elements include activities that are applicable when targeting certain types of
                         infections (e.g., analyzing bloodstream infection data by whether or not the patient had an intrave-
                         nous (PI) catheter).

                         4Because not all hospitals have to meet all elements, when we calculated percentages, we included
                         only those hospitals for which the element was applicable.



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                         Increased Usageof Our Basic Elements Could
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                         were used by at least 70 percent of nonfederal hospitals when
                         appropriate.

                         The three services were similar in the extent to which they used our
                         elements. Forty-two of the elements were used by at least 70 percent of
                         Navy hospitals when applicable, and 41 elements were used by at least
                         70 percent of both Army and Air Force hospitals. Although the number
                         of elements used by the services was similar, the use of a few individual
                         elements varied by service. For example, 77 percent of Navy hospitals
                         that conducted surveillance for surgical wound infections conducted
                         such surveillance at least every 3 days,5 whereas 65 percent of applica-
                         ble Air Force hospitals and 39 percent of applicable Army hospitals did
                         so. In another element, 50 percent of Navy hospitals authorized their
                         nurses to initiate isolation procedures without a physician’s approval,
                         while over 80 percent of Air Force and Army hospitals gave nurses such
                         authority.


                        Certain elements we identified were not widely used by practitioners in
Some Basic Elements     either military hospitals, VA medical centers, or nonfederal hospitals.”
Are Not as Widely       These elements relate to:
Used as Others
                      9 the availability of a physician trained in infection control to serve as
                        consultant for the infection control program,
                      . the specific frequency with which surveillance activities should take
                        place,
                      . the development of baseline rates for specific types of infection, and
                      9 the submission of analyzed infection data to personnel who can take
                        preventive actions.

                        We did not ask respondents to our questionnaire why these particular
                        elements were not as widely used as the others. But some of these ele-
                        ments represent time-consuming surveillance activities. In addition, not
                        one of these elements was required by service regulations.




                        ‘Although our questionnaire states “on average about once every 1 to 3 days,” in this report we
                        simplified this element to “at least every 3 days.”

                        “We define “widely used” as when 70 percent or more of the hospitals used the element.



                        Page 21                                                   GAO/HRD9@74DOD Infection Control
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                                          Increased Usageof Our Basic Elements could
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Trained Physician                         One of our elements calls for infection control programs to have, serving
                                          as consultant or supervisor, a physician who has taken at least one
Consultants Needed for                    training course in hospital infection control. This element has a rela-
Infection Control                         tively low utilization rate in military and nonfederal hospitals and VA
Programs                                  medical centers when compared with most other elements. Service regu-
                                          lations state only that the infection control committee chairman should
                                          be knowledgeable and interested in infection control. According to prac-
                                          titioners whom we contacted, all their hospitals have physicians availa-
                                          ble to the infection control staff as consultants or supervisors. But at
                                          most hospitals surveyed these individuals had not received any training
                                          in hospital infection control programs. Military, VA, and nonfederal hos-
                                          pitals with more than 400 beds were more likely to have a trained physi-
                                          cian than were smaller hospitals in each group. According to Army and
                                          Air Force infection control consultants, some physicians had not
                                          received training in infection control because hospitals lacked training
                                          funds and staffing shortages prevented physicians from leaving hospi-
                                          tals for the period needed to receive such training.

                                          Table 2.1 provides a comparative analysis of the utilization of this ele-
                                          ment by military, VA, and nonfederal hospitals. Utilization of this ele-
                                          ment by service is shown in appendix VI.

Table 2.1: Hospital8 That Do Not Have
Physician Consultant/Supervisor Trained                                                Hospitals without physicians trained in
in Infection Control                                                   Number of                  infection control
                                          Hospital entity               hospitals      Number                       Percentage
                                          DOD                                  77           52                              68
                                          VA                                  158           66                              42
                                          Nonfederal                        3.872        2,051                              53


                                          CDC’SSENIC study showed that a correlation exists between fewer infec-
                                          tions and programs with a physician consultant trained in infection con-
                                          trol. CDC officials still believe that trained physician consultants are
                                          important for an effective infection control program.


Need for Frequent                         Our basic elements call for an infection control practitioner to take steps
Surveillance                              at least every 3 days to (1) determine which nospital patients may have
                                          infections, and (2) identify infections before a patient’s discharge. This
                                          activity-called   case finding-can    be done by reviewing laboratory cul-
                                          tures, reviewing patient charts, and/or asking nurses about patients
                                          with signs or symptoms of infection. These activities are time consuming
                                          and require the practitioner’s continual attention, but performing them


                                          Page 22                                         GAO/HRD!Xh74 DOD Infection Ckmtrol
                                           chapter 2
                                           Increased Usageof Our Basic Elements Could
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                                           at least every 3 days allows the infection control staff to identify prob-
                                           lems and take corrective action before infections get out of control.

                                           CM:  officials believe that case finding should be done at least every 3
                                           days because hospitals are emphasizing shorter lengths of stay for
                                           patients. Thus, if case finding is not done within this time frame, the
                                           program may not identify patients with infections before discharge.

                                           Air Force regulations require hospitals to perform total surveillance and
                                           describe some case-finding activities that practitioners may use. They do
                                           not, however, address the frequency with which case-finding activities
                                           should occur. Neither Army nor Navy regulations address case-finding
                                           methods or frequency. Our questionnaire results indicated that over 30
                                           percent of infection control practitioners are not performing case finding
                                           at least every 3 days for surgical wound, pneumonia, and urinary tract
                                           infections. The Army consultant believes surveillance may not be per-
                                           formed as frequently as every 3 days in some Army hospitals because
                                           infection control staff lack sufficient time to perform the work, particu-
                                           larly part-time practitioners whose other duties may override infection
                                           control responsibilities.

                                           Table 2.2 compares the utilization by military, VA, and nonfederal hospi-
                                           tals of our case-finding frequency elements pertaining to surgical
                                           wound, pneumonia, and urinary tract infections. Utilization of these ele-
                                           ments varied widely by service as shown in appendix VI.

Table 2.2: Hospitals Not Performing Case
Finding at Least Every 3 Days                                                    Number of      Hospitals not performins element
                                           Hospital entity                        hospitals    Number                   Percentage
                                           Surgical wound surveillance                        --
                                           DOD                                           76             31                          ii
                                                                        ._____
                                           VA                                           131             55                          42
                                           Nonfederal                                 3,732          1,671                          45
                                           Pneumonia surveillance
                                           DOD                                          68              22                          32
                                           VA                                           141             62                          44
                                           Nonfederal                                 3,546          1,419
                                                                                                      ~.                            40
                                           Urinary tract surveillance
                                           DOD -                                        75              33                          44
                                           VA                                          141              66                          47
                                           Nonfederal                                3 586           1 6.71                         45




                                           Page 23                                                 GAO/lfRbgO-74 DOD Infection Control
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                             Increased Usageof Our Basic Elements Couid
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                             In contrast to the aforementioned utilization rates, 16 (22 percent) of
                             the 74 applicable military hospitals did not perform case finding for
                             bloodstream surveillance at least every 3 days. Similarly, 17 percent of
                             VA medical centers and 17 percent of nonfederal hospitals did not per-
                             form case finding for bloodstream surveillance at least every 3 days.
                             One possible explanation for the higher use rate is that case finding pro-
                             cedures for 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 infection requires more time-consuming meth-
                             ods. These methods include reviewing laboratory results coupled with
                             discussions with nurses about signs and symptoms of infection in
                             patients or an examination of patients’ medical records.


Need for Baseline Rates by   Baseline infection rates give a hospital an indication of its “normal”
Type of Infection            level of infection, These rates represent the frequency a specific 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 percentage becomes
                             the baseline from which future rates will be measured.

                             Service regulations do not require development of baseline rates for the
                              four major types of infection. The Air Force regulation requires calcula-
                             tion of a hospitalwide baseline rate that would include all types of infec-
                             tions, but does not require baseline rates for specific types of infections.
                             Army and Navy quality assurance regulations require that annual or
                             semiannual rates be calculated for all hospital-acquired infections and
                             for surgical wound infections, but not for the other three types of infec-
                             tions for which we developed elements. According to the Army consul-
                             tant, some Army hospitals do not calculate baseline rates for individual
                             types of infections because Army regulations require annual reporting
                             of an overall hospital infection rate. Our basic elements call for hospitals
                             to develop baseline rates by type of infection.

                             Questionnaire responses indicate that, despite the lack of service
                             requirements, many military practitioners have established baseline
                             rates for each type of infection. Table 2.3 compares the military utiliza-
                             tion of baseline rates with VA and nonfederal hospitals for the four types
                             of infections. Again, utilization of these elements by service is shown in
                             appendix VI.



                             Page 24                                      GAO/HRD90-74 DOD Infection Control
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                                         Increased Usageof Our Basic Elements Could
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Table 2.3: Hospitals Conducting
Surveillance That Do Not Have Baseline                                          Number of            Hospitals without baseline fates
Rates                                    Hospital entity                         hospitals         Number          __-       Percentage
                                         -__
                                         Bloodstream surveillance                                __I~
                                         DOD                                             74               34                                   46
                                                                                                          ___---
                                         VA ~---             --       -~-               152               41                                   27
                                         .-                                                                            --
                                         Nonfederal            __-.-            -      3,648           1,327           -~                      36
                                         _I__.--
                                         Surgical
                                         .___     wound surveillance                                               ~___-.
                                         DOD                                              76            26_____._                              34
                                         VA                                       --is-                 16                                     12
                                         ~_-. - ~-      ~    _.~-~    ~-    -   ._ -
                                         Nonfederal                                    3,732 _____~___ 970                             --      26
                                         Pneumonia surveillance
                                                    _-~--              -~ -___I____
                                         DOD-^-                                          68                31
                                                                                                  .____~._._________~                          46
                                         VA                          ~~ .-- ____ 141                       44
                                                                                                      -~ --____               -__-~~           31
                                         Nonfederal                           ____3,546                 1,150
                                                                                                          ~-.                                  32
                                         Urinary tract surveillance
                                                       .___      ..-.. -        __I.
                                         DOD-.__                      ~-~ ____.          75               33
                                                                                                         .--__                                 44
                                         ~-           _
                                         VA
                                         --.-.      - ~-.     -                          141              38                                   27
                                         Nonfederal                                    3,586           1.Q26                                   29


                                         Four of the nine hospitals we visited compared their current infection
                                         rates with CDCor other published historical rates,’ instead of comparing
                                         current rates to hospital baseline rates. For example, one Navy hospital
                                         computed monthly totals for each of the four major infection types and
                                         compared them with a “nationally accepted monthly total.” CDCofficials
                                         told us this is not an acceptable method of tracking a hospital’s own
                                         performance because hospitals vary by patient characteristics and the
                                         types of procedures they perform.


Infection Control Data                   Thirteen of our basic elements identify specific personnel to whom
Should Be Reported to                    infection data analyses should be provided (e.g., urinary tract infection
                                         data should be analyzed by ward and given to the ward supervisor). Ser-
Personnel Who Can Take                   vice regulations generally do not require infection control practitioners
Preventive Actions                       to accumulate and analyze data by specific groups or individuals, nor do
                                         they require that the data be reported to those groups or individuals.
                                         The closest any come to such a requirement is the Air Force regulation
                                         that requires infection control data to be reported to the infection con-
                                         trol committee. Army and Navy regulations do not contain any require-
                                         ments for reporting infection control data to hospital officials. Although

                                         ‘CDC periodically publishes average rates, by type of infection, from data that an average of about
                                         80 hospitals voluntarily submit monthly.



                                         Page 25                                                    GAO/HRD-90-74DOD Infection Control
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                                           Increased Usageof Our Basic Elements Could
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                                           patient care providers are represented on infection control committees
                                           through their department heads, such representation does not guarantee
                                           that providers receive needed information.

                                           Despite the lack of guidance on who should receive infection control
                                           data, nearly all military hospitals used 6 of these 13 elements. Specifi-
                                           cally, over 80 percent of military hospitals reported appropriate infec-
                                           tion data to the infection control committee and/or surgical wound
                                           infection data to chiefs of surgery and operating room supervisors.

                                           The other seven elements were used, but to a lesser extent. Table 2.4
                                           compares how military, VA, and nonfederal hospitals used the elements
                                           that involve reporting surgical wound infection data to practicing sur-
                                           geons, and bloodstream, pneumonia, and urinary tract infection data to
                                           ward supervisors. Appendix VI shows the extent to which the three ser-
                                           vices used these elements. The remaining elements (reporting to surgical
                                           complications committees, intravenous therapy teams, and respiratory
                                           therapy teams) were applicable to only small numbers of hospitals, and,
                                           therefore, are not shown in the table.

Table 2.4: Hospitals Analyzing
Infections, but Not Reporting Results to                                    Number of                      Hospitals not
Appropriate Personnel                                                        hospitals                  repotting results to
                                                                           performing                 appropriate personnel
                                           Hospital entity                    analysis            Number                Percentage
                                           Bloodstream infection data to ward supervisors
                                           DOD                                          62             24                       39
                                           VA                     -                   148              52                       35
                                           Nonfederal                               2,988             962                       32
                                           Pneumonia infection data to ward suoervisors
                                           DOD                                          58             21                       36
                                           VA                                         135              47                       35
                                           Nonfederal                               2,928             789                       27
                                           Urinary tract infection data to ward supervisors
                                           DOD                                          60             2.5                      47
                                                                                                                                 .-
                                           VA                                        139               44                       32
                                           Nonfederal                              3,051              708                       23
                                           Surgical wound infection data to practicing surgeons
                                           tiOD                                         59             42                       71
                                           VA              ----                         93             72                       77
                                           Nonfederal                              2,973            2.234                       7Fi




                                           Page 26                                            GAO/HRD90-‘74DOD Knfection Control
-
                         Chapter 2
                         kreased Usageof Our Basic Elements Could
                         Improve Infection Control Programs




                         Table 2.4 shows that many hospitals indicated that they analyzed infec-
                         tion data either by ward or by practicing surgeon. But the hospitals are
                         not routinely reporting the analyzed data to ward supervisors or the
                         surgeons involved.

                         Infection control experts indicate that pertinent data on infections
                         should be reported to appropriate hospital personnel who provide direct
                         patient care. With such data, these individuals may have more incentive
                         to change patient care practices to prevent infections. For example,
                         studies by various infection control researchers indicate that reporting
                         surgical wound infection rates to the surgeons who perform the opera-
                         tions has a major effect on reducing infections.

                          The effectiveness of such reporting was demonstrated during our visit
                         to an Army hospital where the practitioner analyzed surgical wound
                         infection data by surgeon and reported the results to the surgical
                         department. This hospital’s practitioner found that the infection rate in
                         the obstetrics section was significantly higher than in the rest of the
                         surgical department over a $-month period. While other surgery sections
                         averaged a 2-percent surgical wound infection rate during this 4-month
                         period, the obstetrical section averaged 20 percent. The practitioner
                         noted that several of the infected patients were treated by the same resi-
                         dent and provided this information to the chief of obstetrics who COLUI-
                         seled the resident. The infection rate in the obstetrical section decreased
                         to about 5 percent over the next 2 months. Army and Air Force consul-
                         tants believe that some hospital infection control programs are not
                         reporting surgeon-specific infection rates because infection control prac-
                         titioners may be intimidated by surgeons who do not necessarily want to
                         receive this information.


                         One basic element was used significantly less in the nonfederal sector
Military and VA Use of   than it was in military and VA hospitals. This element requires that infec-
One Element Differs      tion control practitioners and registered nurses have authority to imple-
Significantly From       ment isolation procedures in an emergency without a doctor’s order; this
                         authority should be in writing. Questionnaire results indicated that
Nonfederal Sector        about 23 percent of military hospitals did not give practitioners and reg-
                         istered nurses this authority. Similarly, 22 percent of VA medical centers
                         did not give nurses this authority. Conversely, about 37 percent of
                         nonfederal hospitals did not give nurses this authority.




                         Page 27                                    GAO/IfRlM@74   DOD Infection Ckmtral
                          Chapter 2
                          Increased Usageof Our Basic Elemente Could
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                          Representatives from the Office of the Assistant Secretary of Defense
Army and Air Force        for Health Affairs and the three services agreed with most of the basic
Consultants Support       elements we developed. In addition, Army and Air Force infection con-
Use of Our Elements       trol consultants supported the use of our basic elements and provided
                          their opinions on the importance of the elements that were not widely
                          used:

                      l   The Army consultant stated that when some kind of surveillance is not
                          conducted at least every 3 days, practitioners miss opportunities to take
                          corrective measures before infections spread.
                      l   An Air Force consultant stated that military hospitals should not com-
                          pare their rates with CDCrates because their patient population is very
                          different from populations served by nonfederal hospitals. The Army
                          consultant also believes this element is important because, without
                          service-specific baseline rates, hospital officials do not know if their cur-
                          rent rates are outside the “normal” or anticipated threshold.
                      l   In addition, an Air Force consultant is concerned that ward supervi-
                          sors-who can greatly influence patient care practices-are not receiv-
                          ing infection control data about their patients,


                          The basic elements we developed are fundamental, generally accepted
Conclusions               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 federal or nonfederal hospitals. Infection control pro-
                          grams in the military, VA, and the nonfederal sector are using most of the
                          elements we developed. This is happening because the practitioners are
                          taking the initiative to determine what elements should be used in an
                          effective infection control program. But the services’ written guidance
                          on the subject lags behind the practitioners’ activities and, in many
                          cases, is so general that it is of questionable value. We believe that the
                          use of the elements that we identified, packaged as a basic infection con-
                          trol program in each service’s regulations, would improve the effective-
                          ness of the military’s programs.


                          We recommend that the Secretary of Defense direct the service secretar-
Recommendation            ies, in conjunction with the Assistant Secretary of Defense for Health
                          Affairs, to update service infection control regulations. At a minimum,
                          the regulations should require components similar to those in our basic
                          elements.



                          Page 28                                      GAO/‘HRMO-74DOD Infection Control
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                  Increased Usageof Our Basic Elements Could
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                  In its March 28, 1990, letter (see app. VII), DODconcurred with this rec-
Agency Comments   ommendation and stated that by May 1990 the Assistant Secretary will
                  direct the services to adopt infection control policies that reflect the
                  intent of the GAO elements and are in compliance with current Joint
                  Commission standards or those of other nationally recognized experts as
                  appropriate, or both. The policies will describe the level of support
                  required for maintenance of the program.




                  Page 29                                      GAO/HRMW74 DOD Infection Control
Chapter 3

Infection CZa-drolShould ReceiveMore
Managerial Attention at All DOD Levels

                          Although our questionnaire showed that military infection control pro-
                          grams used most of our basic elements (see ch, 2), a questionnaire can-
                          not capture how well these programs were integrated and supported
                          throughout the DOD system. Lack of management support and attention
                          can undercut the programs’ effectiveness.

                          Infection control programs at several of the hospitals we visited did not
                          have the resources to adequately perform their activities and were not
                          well monitored by mid-level commands. Of the nine hospitals we visited,
                          six had infection control programs that did not meet service require-
                          ments or perform essential infection control activities because of a lack
                          of resources. Further, both the Army and the Air Force had discontin-
                          ued their mid-level periodic reviews and, therefore, relied on their
                          inspector general surveys to identify weaknesses in infection control
                          programs. However, inspector general surveys conducted at military
                          hospitals did not always identify deficiencies. As a result of these situa-
                          tions, infection control programs were not as effective as they could
                          have been.


                          Infection control is one of many hospital programs competing for rela-
Hospital Management       tively scarce resou: ces. It is also a program that affects many hospital
Does Not Emphasize        activities. At all nine hospitals we visited, hospital commanders had
Infection Control         either not enforced participation in the program by all clinical services
                          of the hospital or not given the program adequate resources to accom-
                          plish its objectives. This reduced each program’s effectiveness. DOD con-
                          curred, stating that infection control programs can benefit from policy
                          guidance and increased management attention. DOD also noted that its
                          review of Joint Commission survey findings suggested that infection
                          control programs can benefit from enhanced oversight and attention.


Hospital Management       To foster an effective infection control program, all departments within
Gives Infection Control   a hospital must actively support and participate in it. At seven of the
                          nine hospitals visited, it appeared that infection control was not consid-
Programs Low Priority     ered a hospitalwide program, and some hospital components gave it lim-
                          ited attention. For example, we found hospital commanders, medical
                          department chiefs, and other key hospital officials who (1) were una-
                          ware of infection control issues within their hospitals or (2) did not
                          assure that their representatives attended infection control committee
                          meetings.




                          Page30                                      GAO/HlW9O-74DODInfectionContro~
                             Chapter 3
                             Infection Control Should ReceiveMore
                             Managerial Attention at Au DOD Levels




                             Concerning the lack of awareness, the chief of medicine at one hospital
                             stated the program was of little benefit to his department and said his
                             main involvement was scanning the infection control committee minutes
                             each month. Yet, he was unaware the infection control program reported
                             on resistant organisms’ and told us that such a report would be very
                             useful. The report on resistant organisms was attached to the committee
                             minutes.

                             At the six remaining hospitals, the lack of support was evidenced by the
                             attendance at the infection control committee meetings. For example,
                             the surgery department’s involvement in the infection control committee
                             had been insufficient at one hospital on various occasions since 1983,
                             and it was not represented at six of the eight infection control meetings
                             held in 1988 before our visit. The infection control committee was par-
                             ticularly concerned about this situation because the surgical wound
                             infection rate had recently increased and committee minutes indicated
                             that the lack of a representative from surgery could affect the hospital’s
                             efforts to reduce the infections. Although the infection control commit-
                             tee had raised the lack of attendance with the surgical director four
                             times since 1983, no action had been taken. In August 1988, the chair-
                             man of the infection control committee notified the commanding officer
                             about the lack of surgical representation on the committee, and a repre-
                             sentative from surgery attended the next meeting.


Hospital Management Did      The infection control programs at six of the nine hospitals we visited
Not Allocate Adequate        suffered because they had too few resources to carry out the program.
                             Practitioners at two Air Force hospitals were concerned that they might
Resources to the Infection   not be able to meet service infection control requirements because of a
Control Program              lack of staff. Practitioners at four Army and Navy hospitals were meet-
                             ing their services’ more limited requirements and were using many of
                             our basic elements. But some elements concerning data analysis and
                             reporting were not being used. In addition, in response to our question-
                             naire, practitioners also wrote that they needed additional resources to
                             accomplish their tasks. For instance, 25 of 77 respondents stated that
                             they needed more staff or more of their time devoted to infection control
                             activities, and 13 practitioners indicated that they specifically needed
                             administrative or clerical support for their program.

                             Air Force regulations require one full-time practitioner for each hospital
                             with 125 or more operating beds. However, at two Air Force hospitals

                             ‘Organisms that are resistant to drugs normally toxic to members of their species.



                             Page 31                                                     GAO/HRD-90-74DOD Infection Control
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we visited (each with one full-time practitioner for about 225 occupied
beds),’ the practitioners were concerned about meeting the Air Force’s
requirement for continuous total surveillance and continuing to perform
all other required infection control activities. In addition to identifying,
analyzing, and reporting infections, these practitioners were responsible
for reviewing hospital operating instructions and conducting orientation
and in-service training for hospital staff. One practitioner was trying to
perform total surveillance. But she stated that the program needed addi-
tional staff to perform surveillance well and also fully perform her other
duties, such as reviewing policies and procedures and assisting with in-
service and orientation training. At the other hospital, the practitioner
was not performing surveillance for urinary tract infections because the
infection control committee decided that the hospital did not have
enough resources to adequately perform total surveillance.” Because uri-
nary tract infections are relatively easy to cure and result in fewer
severe complications, surveillance for this type of infection was
terminated.

 Neither the Navy nor the Army has established infection control staff-
 ing requirements,” and we found that a lack of resources hampered
infection control activities at the hospitals visited, At one Navy hospital,
 no surveillance was performed while one of the two infection control
practitioner positions was vacant. This situation lasted for about a year.
The practitioner present at the hospital stated that she scanned lab
reports for outbreaks of infections but did not have time to perform sur-
veillance. During this time, she said she was also responsible for consult-
ing on infection control related issues for the Naval Medical Command
and other Navy hospitals, counseling employees who may have exposed
themselves to hepatitis or human immunodeficiency virus, developing
and reviewing infection control policies, and providing orientation and
in-service training to hospital staff.

Administrative support was also a concern at six of the nine hospitals
we visited. At these hospitals, the infection control staff either waited
months for the committee minutes and reports to be typed or typed their
own reports and meeting minutes, which took away time from their


‘The Air Force guidance does not authorize additional practit.ioner positions, regardless of hospital
size.

“This form of targeted surveillance would be acceptable under our basic elements.

“A draft Navy infection control regulation will, when implemented, require all Navy hospitals to have
a practitioner and all teaching hospitals to have one practitioner for each 160 beds.



Page 32                                                      GAOBRD-90-74 DOD Infection Control
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infection control duties. For example, the minutes of one infection con-
trol committee indicate that the committee was having difficulty main-
taining program continuity and handling new and ongoing problems
because committee minutes were not being typed in a timely manner.
The program had no designated administrative staff and therefore used
the administrative staff of the quality assurance office. The infection
control committee had waited 2 to 3 months for the minutes to be typed.

Of the three services, only Air Force regulations specifically direct the
hospital commander to provide appropriate administrative support to
accomplish infection control program activities. But two of the Air Force
hospitals we visited did not have any administrative support dedicated
to the infection control program.

Adding staff to the infection control program is not the only solution to
these problems. For example, one Air Force hospital we visited desig-
nated a nurse on each ward as liaison between the wards and the practi-
tioner. These liaisons assisted with in-service training, communicated
policy changes, and observed patient care practices on their wards. This
arrangement allowed the practitioner, who performed this function on a
part-time basis, time to concentrate on activities with the most impact,
such as performing total surveillance.

Computer support is another method of decreasing the time practition-
ers spend on surveillance functions, particularly the analysis of infec-
tions. Infection control literature indicates that time-consuming
surveillance activities (e.g., repeating monthly infection rate calcula-
tions) are especially suited for computers. Eight of the nine infection
control programs at hospitals we visited had access to computers, but
seven infection control staffs were using computers primarily for word
processing because they lacked either training or software for analysis.
For example, at one Navy hospital we visited, the practitioner collected
information about infections, but did not analyze the data to determine
causal factors. She told us that analyzing the data manually was
extremely laborious and she lacked a computer program that could have
expedited the analysis. At one Air Force hospital, the practitioner had
the computer software to analyze infections but used the computer only
for word processing because she did not know how to use the software.

At Army and Navy hospitals, hospital commanders are responsible for
obtaining and distributing computer resources. Air Force officials told
us that the Air Force has bought computers for all its infection control



Ptkge33                                    GAO/RRD-9@74DOD Infection Control
                       Chapter 3
                       Infection Control Should Receive More
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-
                       programs and that most practitioners will receive infection control soft-
                       ware by 1990. The Air Force does not have specific plans to train infec-
                       tion control staff in using this software, although it has required it to be
                       simple enough for nonexperts to operate. According to an Air Force offi-
                       cial, each hospital has a computer systems officer who is familiar with
                       all software in the hospital. In addition, each mid-level command will
                       have one person knowledgeable in using the software who will be avail-
                       able to assist hospital practitioners. We believe that formal orientation
                       training is still necessary for infection control staff to maximize the ana-
                       lytical potential of such software.

                       Presently, DOD is designing or revising hospitalwide and servicewide
                       computer systems5 When completely implemented, these systems will
                       include quality assurance functions, including infection control program
                       activities.


                       The services delegate responsibility for monitoring hospital infection
Command Monitoring     control programs to their mid-level commands, which, in turn, rely upon
of Infection Control   periodic visits by their staff and inspectors general to provide informa-
Programs Is            tion about hospital programs. None of the mid-level commands we vis-
                       ited required the hospitals to submit any information on their infection
Inadequate             control program. As of October 1989, only the Navy required its mid-
                       level staff to visit hospitals on a regular basis (annually) to monitor
                       quality assurance,” including infection control. However, we found that
                       Navy mid-level staff reviewing the infection control program did not
                       always have expertise in infection control. Both the Army and Air Force
                       previously reviewed infection control programs periodically, but, in
                       1985 and 1988, respectively, they discontinued the funding for the
                       reviews. Currently, the Army and Air Force mid-level commands or ser-
                       vice consultants review hospital infection control programs only when
                       requested by the hospital or if an inspector general review identifies
                       serious problems with the program. In lieu of periodic reviews, the
                       Army and Air Force rely solely on inspector general reports to identify
                       deficiencies in hospital infection control programs.

                       In general, we found that visits to a hospital by officials knowledgeable
                       in infection control programs are beneficial. At two hospitals we visited

                       “As of December 1989, GAO was reviewing the installation and operation of DOD’s composite health
                       care system, which DOD estimates will be in full operation by 1995.
                       “In March 1990 DOD officials told us that the Navy no longer requires annual quality assurance
                       monitoring vi&s.



                       Page 34                                                   GAO/HELNl&74 DOD Infection Control
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(one Army and one Air Force), we found evidence that the infection con-
trol program had improved dramatically after discussions with service
consultants or a visit by a mid-level official knowledgeable in infection
control. At these hospitals, the practitioners had no previous experience
in infection control before their being assigned as infection control prac-
titioners. At both the hospitals, the practitioners initially followed the
practice of the prior practitioner and relied on physicians or nurses to
report suspected infections to them instead of performing their own sur-
veillance for infections. Infection control literature indicates that relying
on staff to report infections understates the number of infections and is
not sufficient for an effective program. Shortly after being assigned to
the infection control program, both practitioners requested and received
assistance from service infection control consultants. As a result of
implementing the consultants’ suggestions, at the time of our visits, both
programs had a surveillance program that included most of our basic
elements.

 From 1986 until our visits in 1988, the inspectors general had reviewed
 seven of the nine hospitals we visited. Although our review indicated
that five of these seven hospitals had problems complying with existing
service regulations concerning infection surveillance and committee
attendance, none of the inspector general reports mentioned any infec-
tion control problems at these facilities. One of the reports discussed an
infection control problem at an affiliated clinic. Inspector general teams
may not be able to identify specific infection control weaknesses
because they generally do not include staff knowledgeable about infec-
tion control. In addition, the guidance they follow is not specific enough
to assess how effectively a program is being carried out. Army and Air
Force guidelines for reviewing infection control are based on Joint Com-
mission standards, which are broad, and the Navy inspector general
does not have specific written guidelines for reviewing infection control
programs.

When the inspectors general do identify problems, their recommenda-
tions can have an impact. For example, during 1987 and 1988, the Navy
headquarters and regional inspectors general reviewed the infection
control programs of Navy dental clinics. The inspection reports noted
the presence of infection control manuals at these clinics and recom-
mended that the Naval Medical Command develop similar manuals for
its hospital infection control programs. The Naval Medical Command
assembled a team to write manuals for infection control in hospital and
outpatient settings+ The manuals were completed in January 1989.



Page 35                                     GAO/HRD9&74 DOD Infection control
                      chapter3
                      Infection Control Should Receive More
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                      DODagrees that hospital infection control programs can benefit from
                      official visits by professionals with infection control credentials. DOD
                      further agreed that, although inspector general teams review infection
                      control programs for the services, the services lack guidance requiring
                      either regular evaluation of infection control programs or provisions for
                      planned and systematic consultation and assistance.


                      Hospital management has finite resources available and must allocate
Conclusions           them to the areas of highest priority. As could be expected, our visits to
                      nine hospitals showed that the hospital infection control programs had
                      differing levels of resources. We believe it is the responsibility of each
                      service to determine the priority that should be given to infection con-
                      trol programs and assure that the resources assigned by the hospital
                      commander reflects that priority. Factors that should be considered
                      include the minimum level of staff, computer, and other resources
                      needed to support the level of effort desired in a service’s infection con-
                      trol program. We believe that infection control is a high-priority area,
                      and hospital management should not only give their programs adequate
                      resources but recognition in the form of public support for the principles
                      of infection control and encouragement of infection control activities.

                      The services should also periodically visit hospitals to assure that (1) an
                      appropriate level of resources has been allocated to infection control, (2)
                      the program is supported throughout the hospital, and (3) the program
                      is performing the appropriate activities. We found that hospital visits by
                      headquarters or mid-level command staff familiar with infection control
                      practices and programs are particularly helpful when new infection con-
                      trol practitioners are assigned to a hospital. During this type of visit the
                      headquarters or mid-level staff function more as an advisor rather than
                      a reviewer. Further, hospital visits augment and complement inspector
                      general reviews. Using both the staff assistance visits and inspector gen-
                      eral reviews, the services should have more assurance that infection
                      control programs are effective.


Recommendations       We recommend that the Secretary of Defense direct the service secretar-
                      ies, in conjunction with the Assistant Secretary for Health Affairs, to

                  l   require the surgeons general to determine the relative priority of the
                      infection control programs in relation to other hospital activities and
                      assure that hospitals provide adequate resources for infection control,
                      and


                      Page 36                                     GAO/HRD-9@74DOD hfectlon Conml
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                      Infection Control Should ReceiveMore
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                  . assure that headquarters or mid-level command staff who are familiar
                    with infection control program activities make periodic visits to each
                    hospital to provide technical assistance to the infection control program.


                      In its March 28, 1990, letter, DOD agreed with both of our recommenda-
Agency Comments       tions and stated that by May 1990 action will be taken to implement
                      them. Specifically, DOD will direct the surgeons general to

                  l reemphasize the importance of infection control programs to achieve
                    quality patient outcomes;
                  l review infection control programs and assets, relative to resources, and
                    take corrective action as appropriate; and
                  . provide for both technical assistance and regular evaluation of the full
                    scope of hospital infection control programs.

                      In addition, DOD will pursue refinement and implementation of auto-
                      mated support systems such as the existing Automated Quality of Care
                      Evaluation Support System and the Composite Health Care System cur-
                      rently being developed and tested.




                      Page 37                                   GAO/HRD#O-74DOD InfectIon Control
Appendix I

Methodology Used to Develop the Basic
Elements of an Infection Control Program

                      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.
              l Centers for Disease Control.
              . Joint Commission on Accreditation of Healthcare Organizations.
              . Society of Hospital Epidemiologists of America.
              . Robert W. Haley, M.D., who directed CDC’SSENIC study,

                      We discussed the activities they thought were necessary for an effective
                      infection control program and, working with CDCofficials, compiled a
                      comprehensive list of elements. The list was sent to the above organiza-
                      tions (except CDC)as well as the organizations listed below:

                  l   American Public Health Association.
                  l   Association of Operating Room Nurses, Inc.
                  l   Association of State and Territorial Health Officials.
                  l   Surgical Infection Society.

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

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




                      Page 38                                     GAO,fHRIN&74 DOD Infection Control
Appendix II

Basic Elements of axeInfection Control Program


               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 address program structure, surveillance activities, 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 focuses its attention on only those areas: for exam-
               ple, patients in the intensive care unit or all bloodstream infections. The
               specific elements applicable to an infection control program depend on
               whether the program uses total or target surveillance:

               Total surveillance-all  five groups of elements would be used; however,
               a few individual elements would not be applicable (see the basic
               elements).

               Target surveillance-the   general elements always would be used, and
               depending on the type(s) of infections being targeted in the high risk
               groups, the other appropriate groups of elements would be used (i.e.,
               bloodstream, 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 categories of control func-
               tions because control 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 because the 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-
               ments should be used in conjunction with other standards, such as the
               Joint Commission’s accreditation standards and CJX’Sguidelines.



               Page 39                                      GAO/HRD9@74DOD Infection Control
                                           Appendix II
                                           Basic Elements of an Infection
                                           Control Program




Table 11.1:General Elements (These Apply
to All Hospitals)
                                           Structure
                                           Gl.
                                           The hosDital has at least a Dart-time infection control Dractitioner.
                                           G2.
                                           The hospital has a physician who supervises or consults in the infection control program and
                                           has taken at least one training course in hospital infection control.
                                           G3.
                                           The hospital has a multidisciplinary infection control committee.
                                           G4.
                                           Permanent membership on the committee includes representation           from the following:
                                           -hospital   administration,
                                           -microbiology      laboratory (If one exists),
                                           -medical    staff, and
                                           -nursina 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 infectlon control program has a system to detect and control outbreaks of infections.
                                           Control activities
                                           G9.
                                           The hospital’s infection control program assists in developing and revising hospital
                                           departments’ policies and procedures astheyrelate      to infection control issues.
                                           GlO.
                                           The hospital’s infection control program assists in developing a system for reporting
                                           infections or infection exposures of employees.
                                           Gil.
                                           The hospital’s infection control program assists in identifying and developing infection
                                           control topics for orientation classes.
                                           G12.
                                           The hospital’s infection control program assists in identifying and developing infection
                                           control topics for in-service training.
                                           G13.
                                           The hospital’s infection control program monitors or assists in monitoring the hospital staff’s
                                           compliance with specific patient care practices, such as aseptic techniques during
                                           intravenous catheter insertion and maintenance of insertion sites.
                                           Gl4.
                                           Infection control practitioners and registered nurses on hospitals units have written authority
                                           to implement isolation procedures in an emergency without a physician’s order.




                                           P&ge40                                                    GAO/HEW9@74DOD lnfeetion Control
                                     Appendix 11
                                     Basic Elements of an Infection
                                     Control Program




Table 11.2:Bloodstream Infections
                                                                                                                  Applicability to
                                                                                                                 surveillance type
                                                                                                              Total               Target
                                     Identification
                                     Bl                                                                          X                        X
                                          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:
                                          --Review results of blood cultures in all patients in target
                                             population.
                                          -Review     all patients’ charts in target population.

                                          -Review     all patients’ fever charts in target population.
                                    62.                                                                          X                        X
                                      During the surveillance period, a hospital’s Infectron control
                                      program performs an acceptable case-finding approach
                                      (prevrous criterion) on an average of every 3 days.a
                                    03.                                                                          X                        X
                                      In their case-confirmation effort, infection control staff
                                      perform at least one of the following activities ff 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
                                             populatron as a case-finding activity).

                                          -Review patients’ charts in target population, identified
                                            through case flnding.~.-___
                                    Analysisb
                                    B4                                                                           X                        X
                                      The Infection control program has developed initial
                                       baseline rates for nosocomlal bloodstream infections wlthln
                                       the hospital
                                    85.                                                                          X                        X
                                      Infection control staff analyze nosoconlial bloodstream
                                      infection data by pathogen.
                                                              ~-
                                    B6.                                                                                                   X
                                      Infection control staff analyze data on nosocomial
                                      bloodstream InfectIons by whether or not patient had
                                      peripheral and/or central IV cannulation.
                                    87.                                                                          X                    X
                                      Infection control staff analyze nosocomial bloodstream
                                      infection data by ward.
                                                                                                                            (continued)




                                    Page 4 1                                                       GAO/HRIHO-74 DOD Infection Control
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Basic Element.8of an Jhfection
CxM.rol Program




                                                                     Applicability to
                                                                   surveillance type
                                                               Total                 Target
Reporting
08.                                                                X                      X
  Infection control staff report summarized/analyzed data on
  nosocomial bloodstream infections to the Infection control
  committee.
B9.                                                                                      X
  Infection control staff report summarized/analyzed data on
  nosocomial bloodstream infections to the supervisor of the
  IV therapy team, if one exists.
BlO.                                                               X                     X
  Infectron control staff report summarized/analyzed data to
  the ward supervisors or head nurses.




Page 42                                             GAO/HBurso-74DOD infection Control
                       Appendix II
                       Basic Elements of an Infection
                       Control Program




Table 11.3:Pneumonia
                                                                                                     Applicability to
                                                                                                    surveillance type
                                                                                                 Total               Target
                       Identification
                       Pl.                                                                          X                         X
                             A hospital’s infection control program uses at least one of
                             the following case-finding approaches to identify
                             pneumonia either in all patients or rn 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.

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

                             -Review lab and X-ray results For evidence of pneumonia
                               in patients in target population, identified through case
                               finding (if they do not review lab and X-ray results in all
                               patients in target population as a case-finding activity).

                             -Review patients’ charts in target population, identrfied
                               through case finding.
                       Analysisb
                       P4.                                                                          X                         X
                         The infection control program has developed initral
                         baseline rates for nosocomial pneumonia within the
                         hospital.
                       P5.                                                                          X                     X
                         Infection control staff analyze data on nosocomial
                         pneumonia by pathogen.
                       B6.                                                                                                    X
                         Infection control staff analyze data on nosocomial
                         pneumonia by whether or not patient was on a ventilator, if
                         target population includes ventilator patients.
                       P7.                                                                          X                     X
                         Infection control staff analyze data on nosocomial
                         pneumonia by ward.-.
                       P8.                                                                          X                     X
                         Infection control staff analyze data on nosocomial
                         pneumonia by whether or not patient had surgery, if target
                         population includes surgical patients.
                                                                                                                (continued)




                       Page 43                                                         GAO/HRD-9@74DOD Infection Control
Appendix KI
Basic Elements of a.nInfection
Control Program




                                                                        Applicability to
                                                                       surveillance type
                            -.._                                    Total               Target
Reporting
P9.                                                                    X                     X
   Infection control staff report summarized/analyzed     data on
    nosocomial pneumonia to the infection control committee.
PlO.                                                                                         X
   If target population includes ventilator patients, infection
   control staff report summarized/analyzed     data on
   nosocomial pneumonia to the respiratory therapy
   department. if one exists.
Pii.                                                                   X                    X
   Infection control staff report summarized/analyzed     data on
   nosocomial pneumonia to the ward supervisors or head
   nurses.




                                                                                                 c




Page 44                                                  GAO/HltBW74 DOD Infection Control
                                       Appendix U
                                       Basic Elements of an Infection
                                       Contrnl Program




Table 11.4:Surgical Wound Infections
                                                                                                                   Applicabilit to
                                                                                                                  surveillance i we
                                                                                                      -        Total               Target
                                       Identification           ---- ---
                                                                                                                  X                        x


                                            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 pattents’ charts in target population.
                                       _I_____--__                                                                                   --
                                       s2                                                                         x                        X
                                          During the surveillance period, a hospital’s infection control
                                          program conducts case finding using an acce table
                                          approach (previous criterion) on an average oPevery 3
                                       -__days.”
                                       53.                                                                        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 atients’ charts In target population as a
                                          case-findlng active,Py’




                                            -Review surgical atients’ charts in target population
                                              identified throug t: 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
                                              sigps or symptoms of surgical wound infections in all
                                              patients In
                                                        .----target population
                                                                      ~- --__ as a case-finding activity)
                                       Analysisb                                                                               __-
                                       s4                                                                         X                        x
                                           The i?fection control pro ram has deveioped initial
                                        ,---basellne  rates for surgica 9 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 (for example, clean, clean-
                                       __-.contaminated, .-.-.
                                                             contaminated,
                                                                   _.-      - and dirty).                             -.
                                       57.                                                                        X                       X
                                            Infection control staff analyze surgical wound infection data
                                       __-by pathogen.                                    -__        _~~.__            -
                                       58.                                                                        X                       x
                                           Infection control staff analyze surgical wound infectlon data
                                           by ward.
                                                                                                                             (continued)




                                       Page 45                                                      GAO/HRD9074 DOD Infection Control
                                                                                              f
 Appendix II
 Basic Elements of an Infection
 Control Program




                                                                         Applicabili    to
                                                                        surveillance Y ype
                         I-                                          Total                Taraet
Reporting
s9
   Infection control staff report summarized/anal zed data on
   surgical wound infections to the infection con Yrol          -        x
   committee.
SIO.                                                                     X
   Infection control, staff report summarized/analyzed     data on
   surgical wound Infections to the surgical complications
   committee, If one exists. _.._~
Sll.                                                                    X
   Infection control, staff report summarized analyzed data on
   surgical wound Infections to the chief of i he surgical
   service.                       -
s12.                                                                    X
   Infection control staff report summarized/analyzed     data on
   surgical wound infections to the operating room supervlsor.
s13.                                                                    X
   Practicing surgeons receive surgeon-specific infection
   rates.




Page 46                                                  GAO/HRD-W-74DOD hfection Control
                                      Appendix II
                                      Basic Elements of an Infection
                                      Control Program




Table 11.5:Urinary Tract Infections

                                                                                                                 Appllcablllty to
                                                                                                                surveillance type
                                                                                                             Total               Target
                                      Identification
                                      Ul.                                                                       X                        X
                                         A hospital’s infection control program uses at least one of
                                         the following case-finding approaches to identify urinary
                                         tract infections either in all 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 daysa
                                      u3.                                                                       X                        X
                                        In their case-confirmation effort, infection control staff
                                        perform at roast one of the following activities if they do not
                                        review all pahents 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.
                                      Analysisb
                                      u4.                                                                       X                        X
                                        The infection control program      has developed initial
                                        baseline rates for nosocomial      urinary tract infections within
                                        the hospital.
                                      u5.                                                                       X                        X
                                        Infection control staff analyze    data on nosocomial urinary
                                        tract infectrons by pathogen.
                                      U6.                                                                       X                    X
                                        Infection control staff analyze    data on nosocomial urinary
                                        tract infections by ward
                                                                                                                           (continued)




                                      Page 47                                                     GAO/~W74      DOD Infedon Control
Appendix II
&sic Elements of a.nInfection
Control Program




                                                                                  Applicability to
                                                                                 surveillance type
                                                                              Total               Target
Reporting
u7.                                                                                X                          X
   Infection        staff report summarized/analyzed
               control                                   data on
   nosocomial urinary tract infections to the infection control
   committee.
U8.                                                                                X                          X
  Infection control staff report summarized/analyzed   data on
  nosocomial urinary tract infections to the ward supervisors
  or head nurses.
‘Ymporiant Infection control problems may require case finding more frequently than every 3 days.

bThe proper analysis of infechon data requires calculahon of infection rates In specific patient risk
groups, as well as frequency distributions and line listings of the infectrons 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 betng analyzed, then both the
number of patients with Intravenous catheters and the number of those patients who develop blood-
stream infections are needed




Page 48                                                        GAO/HRD-9074DOD Infection Control
A.ppendix III

Methodology for Sampling Nonfederal Hospitals


                                     The sample of nonfederal hospitals for this study was selected from the
                                     1986 listing of American Hospital Association (AHA) memberships. Since
                                     our questionnaire on infection control was not relevant to very small
                                     hospitals, we excluded memberships with fewer than 50 beds before
                                     selecting the sample. Of the 4,411 memberships with 50 or more beds,
                                     we selected a stratified sample of 550. To insure statistically reliable
                                     estimates for small, medium, and large hospitals, as well as for teaching
                                     and nonteaching hospitals, the sample was selected from five subgroups
                                     (strata) of hospitals (see table III. 1).

Table 111.1:Nonfederal Hospitals-
Sample Sizes and Response Rates by                                                                                             Number of
Strata                                                                          1985 AHA             Initial   Adjusted       responses/
                                     Bed size/affiliation                    memberships           sample       sample’   (response rate)
                                     50-99 beds                                     1,350               110           110          84(76%)
                                     loo-399 bedsjnonteaching                       2,133               110           111               92 (83%)
                                     100-399 beds/teaching                            376               110           110               95(86%)
                                     400 or more beds/nonteaching                         141            90           102               93 (91%)
                                     400 or more 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.


                                     Because we were aware that a small proportion of AHA memberships
                                     covered more than one hospital, we used the 1985 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, obtained
                                     addresses for 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 567 hospitals.

                                     We obtained responses from 85 percent (480 of 567) of the hospitals to
                                     which we mailed questionnaires. Among the sampled subgroups, the
                                     response rate ranged from 76 to 91 percent (see table 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 care beds
                                     reported by the hospital. We excluded 37 hospitals that reported having
                                     fewer than 50 acute care beds. Consequently, our results are based on
                                     the 443 hospitals that reported having 50 or more acute care beds.



                                     Page 49                                                       GAO/~90-74        DOD Infection Chtml
                                                                          .
Appendix Iti
Methodology for Sampling
Nonfederal Hoepit&




Becausedata from 443 hospitals are used to make estimates about the
universe of nonfederal hospitals with 60 or more beds (estimated
number is 3,872 hospitals), all data in this report on nonfederal hospi-
tals are subject to sampling error. The size of the sampling error reflects        1
the precision 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 95percent confidence level. This means            I
that the chancesare about 19 out of 20 that the actual number or per-
centage being estimated falls within the range defined by our estimate
plus or minus the sampling error.




                                                                              ,




                                                                              ?
Page 60                                    GAO/HUD-90-74DODIdection Control   1,
                                                                               f
                                                                              I
                                           Appendix III
                                           Methodology for Sampling
                                           Nonfederal Hospitals




Table 111.2:Estimates and Corresponding
Sampling Errors for Nonfederal Hospitals                                                                            Sampling error at
                                                                                                                            95percent
                                                                                Estimated number       Estimated     confidence level
                                                                                     of applicable   percent that         (r=rcyo;;s,e,
                                           Element                                       hospitals        comply
                                           G2.
                                             Trained physician consultant
                                             (50 to 399 bed hospitals)                       3,363
                                             (400 or more bed hospitals)                       509             2:                     .~;
                                           G14.
                                             Practitioners and registered
                                             nurses have isolatron authority
                                             (100 to 399 bed hospitals)                      2,184             58                        9
                                             (400 or more bed hospitals)                       509             55                        6
                                           Bloodstream infections
                                           82.
                                             Case fIndIng every   3 days
                                                              ___.-                          3,648             83                        5
                                           B4.
                                              Baseline rates                                 3,648             63                        6
                                                                     -.____
                                           87.
                                             Analyze data by ward _..___I                    3,648             82                        5
                                           69
                                              Report data to IV team                           494             57                     17
                                           610.
                                             Report data to ward
                                             suc)ervisors                                    3.648             56                        7
                                           Pneumonia
                                           P2
                                              Case finding every three days -                3,546             60                        7
                                           P4.
                                              Baselrne rates                                 3,546             68                        6
                                           P7.
                                              Analyze data by ward                           3,546             83                        5
                                           PIO.
                                              Report data to respiratory
                                              therapy department                             1,054             60                     11
                                           Pli.
                                              Report data to ward
                                              supervisors                                    3,546             60                        7
                                           Surgical wound infections
                                           52
                                              Case finding every 3 days                      3,732             55               --       6
                                           s4.
                                              Baseline rates                                 3,732             74                        5
                                           s5.
                                              Analyze data by surgeon.I                      3,732             a0              .._-      5
                                           30
                                              Report data to surgical
                                              complications committee                        1,975             62                        8
                                                                                                                           (continued)




                                           Page 51                                               GAO/HRKMO-74DOD Infection Control
Appendix III
Methodology for Sampling
Nonfederal Hospitals




                                                                    Sampling error at
                                                                            9Bpercent
                                Estimated number       Estimated     confidence level
                                     of applicable   percent that         (perq;;;f;
Element                                  hospitals        comply
s13.
  Practicing surgeons receive
  surueon-soeclflc 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
U8.
  Report data to ward
  supervisors                                3,586             65                    6




Page 62                                         GAO/HRB90-74 DOD Infection Control
Appendix IV

Military Hospitals Visited


                832nd Medical Group, Luke Air Force Base, Arizona
Department of   Malcolm Grow USAF Medical Center, Andrews Air Force Base, Mary-
the Air Force   land
                U.S. Air Force Medical Center, Keesler Air Force Base, Mississippi


                Dewitt Army Hospital, Ft. Belvoir, Virginia
Department of   Kimbrough Army Hospital, Ft. Meade, Maryland
the Army        William Beaumont Army Medical Center, Ft. Bliss, Texas


                U.S. Naval Hospital, Bethesda, Maryland
Department of   U.S. Naval Hospital, Camp Pendleton, California
the Navy        U.S. Naval Hospital, San Diego, California




                Page 63                                   GAO/HRJMO-74DOD Infection Control
Appendix V                                                                                             .

Military and Nonfederal Hospitals Use of
GAO’s Basic Elements

                                                                                Nonfederal hospital@
                                                Military hospitals                    (estimated)
                                                 Number       Percent              Number        Percent
               Basic element                   applicable        using           applicable        using
               General element
               Gl                                      77           99                3,872            100
                 Hospital has an infection
                 control oractltioner
               G2.                                     77           32                3,872                46
                 Trained physician
                 consultant
               G3.                                     77          100                3.872                99
                 MultidIsciplinary infection
                 control committee
               G4.                                     77           75                3,872                91
                 Appropriate permanent
                 committee membership
               G.5                                     77          100                3,072                94
                 Meets at least every 2
                 months                _I.
               G6.                                     77           99                3.872                98
                 Surveillance for at least
                 one of the four major
                 infection sites
               G7.                                     77          92                 3,872                97
                 Written criteria for
                 infections at specific
                 sites
               GE.                                     77          97                 3,672                97
                  System to detect and
                  control outbreaks of
                  InfectIons
               G9.                                     77         100                 3.872            100
                  Helps to deveiop hospital
                  infection control pohcies
                  and procedures
               GIO.                                    77          97                 3,872                97
                  Helps to develop a
                  system for reporting
                  employee infections
               Gil.                                    77          95                 3,872                88
                  Helps to develoo
                  infe’ction controi topics
                 for orientation classes
               Gt2.                                    77          95                 3,872            96
                 Helps to develop
                 infection control topics
                 for in-service trainina--
               G13                                     77          94                 3,872            85
                 Practitioners monitor
                 compliance with specific
                 patient care practices
                                                                                              (continued)



               Page 64                                              GAO/ElRMW74 DOD Infection Control
Military and Nonfederal Hospitals’ Use of
GAO’sBasic Elements




                                                                    Nonfe~~&~v~   Ital
                                 Military hospitals                      l      8
                                  Number       Percent                 Number    Percent
Basic element                   applicable        using              applicable    using
G14.                                        77       75                   3,872            63
  Practitioners and
  registered nurses have
  isaation authority
Bloodstream Infections:
61.                                         74       96                   3,648            99
  Appropriate case-finding
  approach
82.                                         74       77                   3,648            83
  Case finding at least
  everv 3 days
B3.                                         74       99                   3648            100
  Appropriate case-
  confirmation approach
                 ..
B4.                                         74       53                   3,648            63
  Baseline rates
85.                                         74       93                   3,648            97
  Analyze data by
  pathogen
B6.                                         27       93                   1,177            90
  Analyze data by whether
  patient had IV
87.                                         74       84                   3,648            82
  Analyze data by ward
BE.                                         74       99                   3,648            99
  Report data to infection
  control committee
B9.                                          4       25                     494            57
  Reoort data to IV team
BlO.                                        74       50                   3,640             56
  Report data to ward
  supervisors
Pneumonia:
PI.                                         68       90                   3,546            93
   Appropriate case-finding
   approach
P2.                                         68       66                   3,546            60
   Case finding at least
   every 3 days
P3.                                         68       99                   3,546           100
   Appropriate case-
   confirmation approach
P4.                                         68       53                   3,546            68
  Baseline rates
P5.                                         68       97                   3.546            97
  Analyze data by
  pathogen
                                                                                  (continued)




Page 65                                               GAO/HRDfHM4     DOD Infection control
Appendix V
Military and Nonfederal Hospitals’ Use of
GAO’s Basic Elementi




                                                                         Nonfederal hospital@
                                         Military hospitals                   (estimated)
                                          Number       Percent              Number       Percent
Basic element                           applicable        using           applicable       using
P6.                                              18          94                  976             90
  Analyze data by whether
  or not patient was on a
  ventilator
P7.                                             68           85                3,546             83
  Analyze data by ward
P8.                                             67           90                3,485             93
  Analyze data by whether
  or not patient had
  surgery
P9.                                             68          100                3,546             99
  Report data to infection
  control committee
PIO.                                            17           24                1,054             59
   Report data to
   respiratory therapy
   department          --.
Pll.                                            68           53                3,546             60
   Report data to ward
   supervisors
Surgical wound                      -
  infections:                   -
Sl.                                             76          92                 3,732             93
   Appropriate   case-finding
   approach
52.                                             76          58                 3,732             55
  Case finding at least
  every 3 days
s3.                                             76          99                 3,732             99
  Appropriate case-
  confirmation approach
s4.                                             76          66                 3,732             74
  Baseline rates
s5.                                             76          78                 3,732             80
  Analyze infection data by
  surgeon
S6.                                             29          79                 1,262             91
  Analyze data by type of
  wound
57.                                             76          92                 3,732             96
  Analyze data by
  pathogen
S8.                                             76          80                 3,732            80
  Analyze data by ward
s9.                                             76         100                 3,732            99
  Report data to infection
  control committee
                                                                                       (continued)




Page 66                                                      GAO/HBD9@74DOD Infection Control
Appendix V
Military and Nonfederal Hospitals’ Use of
GAO’sBasic Elements




                                                                              Nonfederal hospital@
                                      Military hospitals                           (estimated)
                                       Number       Percent                      Number       Percent
Basic element                        applicable        using                   applicable       using
SlO.                                           38            63                       1,975            62
   Report data to surgical
   complications committee
Sll.                                           76            89                       3,732            80
   Report data to chief of
   surgery
512.                                           76            84                       3,732            91
  Report data to operating
  room suDervis.or
s13.        -                                  76            20                       3.732            20
  Practicing surgeons
  receive surgeon-specific
  infection rates
Urinary tract infections:
Ul.                                            75            85                       3,586            90
   Appropriate    case-finding
   approach
u2.                                            75            55                       3,586            55
   Case finding at least
   everv 3 davs              -
u3.    ’      ’                                75            99                       3,586            98
  Appropriate case-
  confirmation approach
U4.                                            75            55                       3,586            71
  Baseline rates             -
u5.                                            75            96                       3,586            98
  Analyze data by
  pathogen
U6.                                            75            80                      3,586             85
  Analyze     data by ward
u7.                                            75           100                      3,586             99
  Report data to infection
  control    committee
U8.                                            75            47                      3,586             65
  Report data to ward
  suclervisors

aThe number of nonfederal hospitals applicable represents an estimate for the universe of all nonfederal
hospitals, based upon responses to our questionnaire, and sampling errors must be taken into account
when drawing conclusions from the percentages (see app. Ill).




Page 67                                                      GAO/HEIWO-74       DOD Infection Control
Appendix VI

lbIilitary Hospitals’ Use of SelectedInfection
Control Basic Elements

                                         Chapter 2 compares the military, VA, and nonfederal hospitals’ use of
                                         our basic elements and concludes that these three hospital sectors are
                                         similar in their use of the elements. However, within the military, we
                                         found differences in the services’ use of specific elements. The tables
                                         that follow detail the use of some of our basic elements among Air
                                         Force, Army, and Navy hospitals. The elements selected were those gen-
                                         erally not used by military hospitals and correspond to the elements in
                                         tables 2.1 to 2.4 in chapter 2.

Table Vi.1: Hospltair That Do Not Have
Physician Consultants/Supervisors                                                      Hospitals without physicians trained in
Trained in infection Control             Hospital                 Number of                       infection control
                                         entity                    hospitals           Number                       Percentage
                                         Army                             32                22                              69
                                         Navy                             22                13                              59
                                         Air Force                        23                17                              74
                                         Total                           77                 52                              66


Table Vi.2: Hospital8 Not Performing
Case Finding at Least Every 3 Days                                        Number of       Hospitals not performing element
                                         Hospital entity                   hospitals     Number                   Percentage
                                         Surgical wound surveillance
                                         Army                                     31             19                         61
                                         Navy                                     22              5                         23
                                         Air Force                               23               7                         30
                                         Total                                   76              31                         41
                                         Pneumonia surveillance
                                         Army                                     26             11                         42
                                         Navy                                    21               4                         19
                                         Air Force                               21               7                         33
                                         Total                                   66              22                         32
                                         Urinary tract surveillance
                                         Army                                    31              21                         68
                                         Navy                                    22               6                         27
                                         Air Force                               22               6                         27
                                         Total                                   75              33                         44




                                         Page 68                                          GAO/HRD-90-74DOD Infection   Control
                                         Appendix VI
                                         Military Hospitals’ Use of SelectedInfection
                                         Control Basic Elements




Table Vl.3: Hospitals Conducting
Surveillance That Do Not Have Baseline                                            Number of      Hospitals not performing element
Rates                                    Hospital entity                           hospitals     Number                 Percentage
                                         Bloodstream surveillance
                                         Army                                             30           13                       43
                                         Navy                                             22           11                       50
                                         Air Force                                       22            IO                       45
                                         Total                                           74            34                       46
                                         Surgical wound surveillance
                                         Army                                            31            13                       42
                                         Navy                  ---.                      22             6                       27
                                         Air Force                           -.          23             7                       30
                                         Total                                           76            26                       34
                                         Pneumonia surveillance
                                         Army                                            26            11                       42
                                         Navy                   -.-                      21            12                       57
                                         Air Force                                       21             0                       38
                                         Total                                           68            31                       46
                                         Urinary tract surveillance
                                         Army                         “.~_               31           12                        39
                                         Navy                                            22           13                        59
                                         Air Force                                       22            8                        36
                                         Total                                           75           33                        44




                                         Page 69                                               GAO/HRIHO-74 DOD Infection Control
                                            Appendix VI
                                            lblllitary Hospitals’ Use of SelectedInfection
                                            Control Basic Elements




Table Vl.4: Hospitals Analyzing
Infections, but Not Reporting Results to                                              Number of
Appropriate Personnel                                                                  hospitals     Hospitals not reporting results to
                                                                                     performing             appropriate personnel
                                           Hospital entity                              analysis Number
                                                                                                   -~                          Percentage
                                           Bloodstream infection
                                                            ..-           data to ward supervisors                              ____-
                                           Army                                                25       11                               44
                                           Navy                                                19         7   _..-                       37
                                                                    ____---
                                           Air Force                   .-                      18         6                       -~     33
                                           Total                                              62        24                               39
                                           Pneumonia infection
                                                         --            data  to ward  supervisors        --I___
                                           Army                 _--           ~                20       10                               50
                                           Navy            .-                                  19   ___. 7                               37
                                           Air
                                           ._. Force                                           19         4                              21
                                           Total                                              56        21~._____                        3z
                                           Urinary tract infection data to ward supervisors                                           -~
                                           Glly                     ~-                        22        13                               59
                                           Navy                                              20~~~..      8                             40
                                           Air Force                                         18  4                                     22
                                           Total                                      60       25             ‘.                       42
                                           Surgical wound infection data to practicing surgeons
                                           Army                      .~._____.        22        19                                     86
                                           Navy                                       19        13                                     68
                                           Air Force                                  18       10                                      56
                                           Total                                      59       42                                      71




                                           Page 60                                                     GAO/HRD90-74DOD Infection Control
Comments From the Department of Defense



                                         THEASSISTANTSECRETARYOF              DEFENSE
                                                WASHINGTON       D.C. 20301-1200




            Mr.     David      P. Baine
            Director,          Federal Health Care
              Delivery          Issues
            Human ReSOUrceS      Division
            U.S. General Accounting           Office
            Washington,     D.C.       20548
            Dear Mr.         Baine:
                   This       is the
                                Department      of Defense (DOD) response to the
            General                 Office
                            Accounting         (GAO) draft   report,    "INFECTION
            CONTROL: Military       Programs are Comparable to VA and Nonfederal
            Programs but Can Be Enhanced,"            dated February      1, 1990 (GAO Code
            code 101337/0SD Case 8236).            The DOD concurs with the GAO
            findings    and recommendations.         The DOD will    continue    efforts      to
            facilitate     and improve program management practices            through      the
            implementation     and refinement       of automated data systems.           In
            addition,    the DOD will      forward   a memorandum within      60 days,
            directing    that the Services:
                  --   Adopt infection        control    policies   that reflect                   the intent
            of the GAO elements          and are in compliance        with current                   Joint
            Commission on Accreditation             of Healthcare     Organizations
            Standards      and/or    those of other nationally         recognized                  experts   as
            appropriate,         (The policies      should describe      the level                 of support
            required     for the program).
                --     Reemphasize the importance                       of infection     control     programs
            to quality    patient  outcomes.
                 --   Review infection                 control       programs and assets,     relative
            to resources,   and take                corrective        action  as appropriate.
                   It is DOD policy        that hospitals           have programs for the
            continuous      monitoring       of patient         care.     Patients     have the right
            to care and treatment            in a safe environment.                The DOD
            appropriately       delegates        responsibility         for the development          of
            policies      and procedures         related      to infection       control   to Service
            experts.       The DOD agrees that each Service                   must specify     the
            elements      basic to its infection              control    program and describe           the
            level    of support      required       for the maintenance            of the program.
            The DOD fully       supports       the value of official             technical    assist
            and evaluation       visits      by knowledgeable           professionals,       and
            recognizes      that DOD programs can benefit                  from increased      policy
            guidance      and management attention.




                      Page 61                                                      GAO/H&D-90-74M)D Infection Ckmtrol
       CommentsProm the Department of Defense




      The detailed     DOD comments on the report      findings    and
recommendations       are provided   in the enclosure.       A few additional
technical    corrections     were separately  provided.        The Department
appreciates     the opportunity    to comment on the GAO draft         report.
                                        Sincerely,




Enclosure
as stated




       Page 62                                         GAO/HRD-90-74DOD Infection Control
                                      Appendix VU
                                      CommentsFrom the Department of Defense




                                                GAO   DRAFT REPORT - DATED FEBRUARY 1, 1990
                                                       (GAO CODE 101337) OSD CASE 6236

                                    "INFECTION CONTROL: MILITARY PROGRAMSARE COMPARABLE TO
                                         VA AND NONFEDERAL PROGRAMSBUT CAN BE ENHANCED"
                                                         DEPARTMENT OF DEFENSE COMMENTS
                                                                            l *****


                                                                          FINDINGS
                            FINDING A: Basic Elements Of An Infection                       Control      Prosra m.
                            The GAO reported          that the Office        of the Assistant           Secretary      of
                            Defense for Health Affairs              has delegated        responsibility          for the
                            development        and implementation          of policies      and procedures          related
                            to infection        control     to the Military        Services.        The GAO further
                            reported     that,     in turn,     the Services       require    their      hospitals       to
                            operate    infection        control    programs to identify          existing
                            infections      and help prevent          future   occurrences.
                            The GAO explained            that,     in order to assess the programs operating
                             in military       hospitals,        it needed criteria             outlining        the basic
                            elements      of an effective            infection        control    program.          The GAO
                            found, however,          that the program guidance                  developed       by the DOD
                            was too broad to serve this purpose.                          The GAO also found that the
                            guidance      on infection         control        programs that existed              in the health
                            care community,          in general,          was either        outdated,      did not cover
                            all the major components of a program,                          or was not specific             as to
                            the basic elements             of a program.            The GAO reported,           therefore,
                            that it worked with representatives                         of nine organizations             and one
                            other individual           with expertise            in infection        control       to develop a
                            list    of 56 basic elements               of an effective          program in five
                            categories--(l)          general       elements,         (2) bloodstream         infections,         (3)
                            pneumonia,        (4) surgical         wound infections,            and (5) urinary           tract
                            infections.          The GAO noted that these elements                      are applicable          to
                            infection       control      in any hospital            with over 50 acute-care               beds.
                            The GAO reported           that it used these elements                   to examine military
                            hospital      infection        control      programs.         The GAO collected
                            information        through      onsite      visits      to nine military           hospitals,       as
                            well as through          a questionnaire             sent to all       79 military        hospitals
                            with more than 50 acute-care                    beds, to all Veterans              Administration
Now on pp. 2-3, 11 to 13,   medical      centers,      and to a sample of 567 nonfederal                       hospitals.
17 to 20, and 38 to 48.      (pp. 2-3, pp. 12-14, pp. 23-28, pp. 58-72, GAO Draft Report)

                            DOD Resnonse:           Concur.    The DOD agrees             that in order to assess
                            infection       control     programs operating     in           military   hospitals,
                            Service      program guidelines        are needed.              The DOD delegates
                            responsibility          for the development     and           implementation      of policies




                                      Page 63                                                     GAO/HRD-9374      DOD   Infection Control
                                    Appendix VU
                                    CommentsFrom the DepartmentofDefense




                           and procedures   related     to infection  control      to the Services.
                           Program components      should be approved and periodically          revised    by
                           content  experts   within    each Service.    Infection      control  practices
                           are not static   and    must be regularly   evaluated.
                           The elements     developed      by the GAO contain     important    components                        of
                           an infection     control     program.   These components were considered
                           by the Joint     Commission on Accreditation          of Healthcare
                           Organizations      in the revision     and publication      of the 1990
                           Infection     Control    Standards.
                           Of note, the 1990 edition       of the Accreditation                      Manual for
                           Hoswitals   has revised    completely   the Infection                     Control
                           Standards.     The changes,   contained    in Appendix                    B of the 1990
                           edition,   were summarized as follows:
                                         "The new infection            control     standards        and required
                                         characteristics          are less detailed,            include      more
                                         liberalized        surveillance        definitions         to accommodate
                                         methods other than whole house surveillance                            (for
                                         example,      focused surveillance              or surveillance            by
                                         objectives),        place greater         emphasis on prevention                 and
                                         control      of infection,        and are less prescriptive                   with
                                         regard to the structure               of the infection           control
                                         program,      thereby      broadening       a hospital's         flexibility         in
                                         adopting      state-of-the-art          infection        control      practices."
                           In view of these recent      improvements,  the DOD shall                         continue       to
                           require   a compliance   with Joint   Commission Standards                         for all
                           fixed   hospitals   of more than a 25 bed capacity.
                           The DOD agrees that each Service         has an obligation     to its
                           patients  and practitioners      to attempt   to identify    improved
                           infection  control     practices   and the levels    of support   required
                           for the programs.
                           FINDING B: Military                Practitioners        Utilize     Many Basic Elements on
                           Their Own Initiative.                 The GAO found that           Service     guidance     on
                           infection       control      programs requires            the use of few of the
                           elements       developed       by the GAO.          The GAO reported,           for example,
                           that of the 56 elements                 it developed,         Air Force instructions
                           specify      31 elements,         Navy instructions             13, and Army instructions
                           10.      Based on its analysis              of questionnaire         results,       however,    the
                           GAO found that 41 of the 56 elements were actually                               being used by
                           at least       70 percent        of military        hospitals      when such use was
                           appropriate--        a utilization          rate the GAO characterized               as
                           excellent       and largely         attributable        to the professionalism            of the
                           practitioners.           The GAO reported,            for example,        that practitioners
                           at the nine hospitals               visited      took the initiative           to take
                           training,       contact      others,       or read literature          on infection       control
                           programs.         The GAO observed           that,    as a result,        some activities
                           went beyond Service              guidance      and included        many of the basic
                           elements       developed      by the GAO. The GAO noted the extent                      of the
                           elements       usage in military            hospitals      was similar       to that found in
Now on pp, 3, 17, 20-21,   both Veterans          Administration          medical     centers     and nonfederal
and 49-57.                 hospitals.          (p-3, p-23, pp. 28-29, pp. 79-83, GAO Draft Report)
                                                                          -2-




                                    Page 64                                                     GAO/HRD-SC-74DODInfection Control
           Appendix VJI
           CommentsFromtheDepartmentofDefense




 w:                   Concur.       It is DOD policy         that hospitals       have
 programs for the continuous              monitoring       and evaluation      of patient
 care.    The prevention        of infection         is a fundamental        goal of
 clinical   practice.       Infection       control      is an essential       element of
.peer review    and a category          of evaluation        required     for the
 granting   of clinical       privileges.          Patient     care providers      are
 taught   to prevent     infection,        promote health,         and protect     both
 patients   and co-workers          from infection.
 It is also DOD policy            that military          hospitals        comply with Joint
Commission guidelines.               The 1990 Accreditation
Hospitals       Standard     IC.2.1.2      states      that "the infection             control
committee       includes     an individual          whose credentials            document
knowledge       of, and special         interest       or experience          in, infection
control.*1        Standard     IC,3 states        that "responsibility              for the
management of infection              surveillance,          prevention,         and control       is
assigned      to a qualified         person."        Standard        TC.3.1 requires         that
 "there    be documented evidence              that the person has education,
training,       or supervised        experience        related       to infection
surveillance,         prevention       and control.il            Finally,    IC.4.1.     states
that "all       personnel      are competent         to participate          in infection
monitoring,        prevention,       and control         activities        and are provided
with any necessary           orientation,         on-the-job         and in-service                     c
training,       and continuing         education."
FINDING C: 1Some of The Bas'c                       s Wide1                                    sed.
The GAO found that 15 of the basic elements    it identified                                   were
not being used as frequently   as the 41 elements   referred                                 to in
Finding    B. According to the GAO, these elements    related                                to the
following:
      --      the    availability          of a trained  physician              consultant       for
              the    infection         control  program;
      WI      the specific             frequency    with which     surveillance
              activities            should take     place:
      --      the development            of baseline      rates    for    specific       types     of
              infection:  and
      De      the submission  of analyzed     infection                  data     to personnel,
              who can take preventive    actions.
The GAO provided          a comparative       analysis      of the utilization        of the
elements     by military,        Veterans     Administration,         and nonfederal
hospitals.        The GAO pointed         out that it did not ask the
questionnaire         respondents     why these elements           were not as widely
used as others.           The GAO ObseNed,         however,      that one of these
elements     represents      time    consuming surveillance            activities.      In
addition,      the GAO observed that none of these elements were
required     by Service      regulations.         Rather,     the GAO observed that
the service       written    guidance      lags behind the practitioners'
activities       and, in many cases, is so general                 that it is of
questionable       value.      The GAO concluded          that failure        to use these

                                                   -3-




           Page 66                                                  GAO/HRDM-74 DOD Infection control
                                      Appendix VII
                                      CommentsFrom the Department of Defense




                             elements     hampers the effectiveness         of an infection      COntrOl
                             program.       The GAO further       concluded  that the use of the elements
                             it identified,        packaged as a basic infection         control   program in
                             each Service       regulation,      would improve the effectiveness         of the
Now on pp,4, 17, 21 to 27,   military     programs.         (p. 4, p. 23, pp. 29-41, p. 44, pp. 84-07,
28,and 58 to 60.             GAO Draft Report)
                             moonsg:              Concur.      The DOD agrees that a successful
                             infection    control     program should incorporate               recognized     essential
                             elements.      Accordingly,       as discussed         in the DOD response to
                             Recommendation       1, by May 1990, the Office               of the Assistant
                             Secretary    of Defense (Health            Affairs)      will  direct    the Services       to
                             adopt infection       control     policies       that reflect       the intent    of the
                             GAO elements      and are in compliance             with Joint      Commission
                             Standards.      It should be understood              that "essential        elements8' may
                             change.    For    example,     the 1990 Joint          Commission Infection         Control
                             Standards    no longer      recruire     the availability         of a trained
                             physician    consultant.
                             FINDING D: plilitarv           And Veterans         Administration          Use of One
                             Element Differs        Sisnificantlv.            The GAO noted that one basic
                             element was used significantly                 less in the nonfederal               sector    than
                             it was in military          and Veterans         Administration          hospitals,       the
                             element requiring         that infection          control     practitioners          and
                             registered      nurses have authority             to implement         isolation
                             procedures      in an emergency without              a doctor's        order--and       that
                             this authority        be in writing.           According      to the GAO, its
                             questionnaire       results      showed that about 23 percent                  of military
                             hospitals     and 22 percent            of Veterans     Administration           medical
                             centers    did not give        practitioners         and nurses this authority.
                             The GAO reported        that conversely,            about 37 percent           of nonfederal
Nowonp.27.                   hospitals     did not give         nurses this authority.              (p. 42, GAO Draft
                             Report)
                             DOD Resaonse:           Concur.       The 1990 Joint       Commission Infection
                             Control     Standards        (IC.2.5)     state that "the authority          of the
                             infection       control     committee,       or its designee,      to institute       any
                             surveillance,         prevention,       and control      measures or studies         when
                             there     is reason to believe            that any patient      or personnel        may be
                             in danger,       is defined        in writing     and approved by the
                             administration          and medical       staff."     Service   compliance      with   this
                             standard      is necessary         to achieve     accreditation      status.




                                                                            -4-




                                      Page66                                                    GAO/HRIMO-74 DOD Knfection C~IWOI
                          Appendix VU
                          CommentsFrom the Department of Defense




               FINDING E: A3         and hi     arc                                   he Use of the
               GAO Elements.      The GAO reported       that DOD officials          generally
               agreed with most of the GAO basic elements               used as criteria        for
               an infection    program.     In addition,      the GAO reported         that Army
               and Air Force infection        control    consultants       supported     the use of
               the GAO basic elements.         The GAO cited       several     examples of the
               importance    of the elements      not widely     used, as follows:
                     we      the Army consultant        stated    that, when surveillance    is
                             not conducted      at least     every three days, practitioners
                             miss opportunities       to take corrective     measures before
                             infections   spread:
                     --      an Air Force consultant          stated    that military      hospitals
                             should not compare their           rates with Centers       for Disease
                             Control     rates,     because of differences       in patient
                             populations        with nonfederal     hospitals;
                     --      in addition,       the Army consultant       noted the importance         of
                             developing      baseline      rates because,   without     service-
                             specific     baseline      rates,   hospital  officials     do not know
                             if their     current     rates are outside      the normal     threshold:
                             and
                     --      an Air Force consultant      was concerned              that ward
                             Supervisors,    who can greatly   influence               patient care
                             practices,   are not receiving    infection               control data
                             about their   patients.
               Overall,      the GAO observed that the elements                  it developed      are
                (1) fundamental,        (2) generally          accepted by infection         control
               practitioners        in both public         and private       sectors,     and (3)
               supported       by organizations       knowledgeable          about infection
               control.        The GAO concluded         that,     cumulatively,       the elements    form
               the basis for an effective              infection       control     program,   whether    in
Nowon   p.20   Federal      or nonfederal      hospitals.          (pp. 42-44, GAO Draft Report)
               m:                   Concur.  The DOD agrees that several     of the GAO
               elements     are fundamental   components of a comprehensive     infection                            c
               control     program and could be incorporated     into Service
               guidelines.        (See the DOD response to Finding    A and
               Recommendation       1).
               FINDING:           Hosaital      Management Places A Low Prioritv                On
               f.In ection                                   The GAO observed that,           in order to
               foster     an effective        infection       control    program,    all departments
               within     a hospital       must actively         support    and participate        in the
               program.       The GAO found, however,               that at seven of the nine
               hospitals      visited,      it appeared that infection              control     was not
               considered       a hospital-wide           program-- and it was given limited
               attention      by some hospital            components.       The GAO cited       several
               examples where hospital               commanders, medical         department      chiefs,
               and other key hospital              officials      gave infection       control     programs
               low priority.           At one hospital,         the GAO reported        the chief      of
               medicine      was unaware of an infection                control   report     that was
               available      within     his hospital.          At the six other        hospitals,       the
                                                          -5-



                          Page 67                                               GAO/HRD-99-74DOD Infection Control
                                                                                                                                     .
                                      Appendii VII
                                      CommentsFrom the Department of Defense




                           GAO found the lack     of support      was evidenced        by the low attendance
                           at the infection    control      committee     meetings.       The GAO noted that,
                           at one hospital,    the surgery       department's       involvement      in the
                           infection   control   committee     had been insufficient            for at least
                           five years-- and it. was not represented            at six of the eight
                           infection   control   meetings     held in early        1988.     The GAO concluded
                           that the low priority       given infection        control     programs by
                           hospital  management is one indication            that hospital         management
Now on pp,4,   and 30-31   does not emphasize     infection      control.       (p- 5, pp. 45-48, GAO
                           Draft Report)
                           DOD Resaonse:              Concur.     Infection          Control    programs can benefit
                           from policy          guidance      and increased            management attention.
                           Definitive          actions      and timely        correction       of problems were not
                           evident      in the GAO study.               Oversight        and communication           of
                           long-standing            infection     control         program requirements            appeared to
                           be deficient.              As discussed        in the DOD response to Recomendations
                           2 and 3, by May 1990, the Assistant                          Secretary      of Defense (Health
                           Affairs)       will      direct    the Services           to evaluate       existing      infection
                           control      program performance.                  The DOD will        continue      to pursue
                           implementation             of automated       data processing           through      refinements
                           in the Automated Quality                 of Care        Evaluation      Support System and
                           installation           of the Composite Health Care System, as discussed                            in
                           the DOD response              to Finding      G. In addition,             the DOD will
                           continue       to take advantage             of patient        care monitoring
                           opportunities            that exist      in the Civilian           External        Peer Review
                           Program, such as analysis                  of wound infection             rates throughout
                           Service      medical        treatment      facilities.
                           The Joint       Commission,       mindful     of the key role         management holds in
                           effecting       a quality     assurance       program,     has implemented         Governing
                           Body Standard         GB.1.18,     which states      that,      "The governing        body
                           provides      for resources        and support      systems for the quality
                           assurance       functions     and resource        management functions           related    to
                           patient    care and safety."              Those hospitals        that demonstrate         a
                           failure    to organize        and manage a strong           infection      control     program
                           will    be cited      on surveys.         The accountability          of responsible
                           commanders, as well as the effectiveness                      of Service     and DOD
                           policy,    will     be evaluated.
                            FINDING G: Hosvital            Manaaement Did Not Allocate                     Adequate
                           Resources      to the Infection             Control       Procrran.        The GAO found that
                            infection     control     programs at six of the nine hospitals                            visited
                           suffered     because they had too few resources                          to carry out the
                           program.      The GAO reported              that Air Force regulations                   require    one
                            full-time    practitioner          for each hospital               with 125 or more
                           operating     beds.       The GAO found that practitioners                         at two Air
                           Force hopitals         it visited         were concerned            they might not be able
                           to meet infection          control        requirements          because of a lack of
                           staff.      The GAO further           found, however,             that neither         the Navy nor
                           the Army has established                infection         control      staffing      requirements.
                           In addition,       the GAO found that a lack of resources                            hampered
                           infection     control      at the Army and Navy hospitals                       it   visited.       As
                           an example,      the GAO reported               that at one Navy hospital,                  no
                           surveillance       was performed            for    about one year--while               one of two
                           infection     control      practitioner            positions        was vacant.
                                                                                  -6-



                                     Page 68                                                     GAO/HEW90-74DOD Infection Control
                                      AppendkW
                                      CommentsFromtheDepartmentofDefense




                           In addition,         the GAO found that administrative              support     for
                           infection      control      activities        was a concern at six of the
                           hospitals      it visited.           According     to the GAO, only the Air Force
                           regulations        specifically        direct    the hospital    commander to provide
                           appropriate        administrative         support    to accomplish    infection
                           control     activities.          The GAO found, however,         that two of the Air
                           Force hospitals          it visited       did not have any administrative
                           support     available       to the infection         control  program.
                           The GAO observed that adding staff                          is not the only solution                    to
                           the identified          problems.          The GAO found,              for example,           that at one
                           Air Force hospital,             a nurse was designated                     as liaison         between the
                           wards and practitioner--               allowing         the practitioner                more time to
                           concentrate        on activities           with the most impact.                      The GAO also
                           observed      that computer support                 is another           method of decreasing
                           the time      practitioners          spend on surveillance                     functions.
                           According       to the GAO, eight              of the       nine     infection          control
                           programs at the hospitals                  visited        had access to computers--but
                           staff    at seven of the hospitals                    lacked either              training       or
                           software      for analysis.            The GAO concluded                 that the absence of
                           adequate resources            is another          indication           that hospital            management
                           does not emphasize            infection          control.          The GAO further              concluded
                           that it is the responsibility                     of each Service               to determine          the
                           priority     that should be given to infection                             control       programs and
                           to assure that the resources                     assigned        reflect        that priority.             The
                           GAO also concluded            that,      in its       view,      infection           control     should be
                           a high    priority       area--that          hospital         management should give their
                           programs not only adequate resources,                            but also recognition                 in the
Now on pp. 4, 30, 31-34,   form of public          support      for the principles                  of infection           control
and 35.                    and encouragement           of infection            control        activities.             (P. 5, P- 46,
                           pp. 40-53, p. 56, GAO Draft Report)
                           DOD ReSDOnSe:          Concur.        It should be recognized,            however,     that
                           quality     patient     care must be the number one priority.                     It is
                           difficult      in the real world of resource                 constraints      to fully      fund
                           and staff      all program        requirements        at all times.        Maximum
                           efficiency       of existing        resources      is a goal.       A DOD review of
                           recent     Service     Joint    Commission Survey findings               suggests    that
                           infection      control      programs can benefit           from enhanced oversight
                           and attention        to detail.          In addition,      the DOD is taking         steps to
                           improve infection           control     automation      through     enhancements       in both
                           the Automated Quality             of Care Evaluation          Support System        and the
                           Composite Health Care System.
                           FINDING H: Extent                                                        nfection       Control
                           Proqrams.         The GAO explained            that the Services            delegate
                           responsibility           for monitoring          hospital      infection        control    programs
                           to their       mid-level         commands which,        in turn,       rely upon periodic
                           visits    by their         staff    and inspectors          general      to provide
                           information        about hospital          programs.         The GAO found, however that
                           none of the mid-level               commands visited          required       the hospitals          to
                           submit any information                on their     infection       control       programs.         The
                           GAO reported         that Navy mid-level             quality      assurance       staff    visit
                           hospitals       regularly,         but do not necessarily              have expertise           in
                           infection       control.          The GAO found that Army and Air Force


                                                             -                 -7-



                                     Page69
                                       AppendixVIl
                                       CommentsFrom the DepartmentofDefense




                              mid-level    commands review their    hospitals'     infection      Control
                              programs only when requested       by the hospital,       and rely on
                              Inspector    General reports to identify       weaknesses      in infection
                              control   programs.
                              The GAO found that visits              to a hospital       by officials
                              knowledgeable       in infection         control    are beneficial.       The GAO
                              reported,     for example,       that at two hospitals            visited  there was
                              evidence    that the infection            control     program improved dramatically
                              after   discussions       with Service         consultants    or after    a visit by a
                              knowledgeable       mid-level      official.
                              The GAO also reported              that,      from 1986 to early            1988, the Service
                              Inspectors         General had reviewed               seven of the nine hospitals
                              visited.        The GAO found, however,                  that although       five of the seven
                              hospitals       had problems complying                 with existing        service
                              regulations,         none of the Inspector                 General reports        mentioned      any
                              infection       control     problems        at these facilities.               The GAO observed
                              that this may be because (1) Inspector                           General teams do not
                              include      staff    knowledgeable           in infection          control    and (2) the
                              guidance      they follow        is not specific              enough to assess program
                              effectiveness.            The GAO pointed             out that,      when the Inspectors
                              General do identify            problems,          their     recommendations         can have
                              impact,      as evidenced       by a Navy review of infection                     control
                              programs in its dental               clinics.           The GAO concluded         that the
                              Services       should periodically              visit      hospitals      to assure that        (1)
                              an appropriate          level   of resources             has been allocated           to infection
                              control,       (2) the program is supported                    throughout      the hospital,
                              and (3) the program is performing                        the appropriate         activities.
                              The GAO further     concluded  that,  by using both the staff
                              assistance   visits   and Inspector   General reviews,   the Services
                              should have more assurance       that infection  control   programs are
NOW   on pp 4,30, and 34 to   effective.     (P. 5, Pm 45, PP. 53-57, GAO Draft Report)
36.
                              DOD Resnonse:           Concur.          The DOD agrees that official               visits        to
                              hospitals        by professionals              with credentials        in infection          control
                              and surveillance            can be beneficial.               The inspection       process         in
                              Navy medical         treatment         facilities       changed in October 1989 when
                              the Bureau of Medicine                 and Surgery started           a command inspection
                              program.         The inspection           team      can be augmented by an
                              Environmental          Health Officer             and/or Preventive        Medicine       Officer.
                              The eight mid-level               regional        geographic    commands were dissolved
                              as of October 1, 1989.                  Health Service         Support Offices         have been
                              established.           Each office          has a Quality       Assurance/Nurse           billet.
                              While the Quality             Assurance         officer    may not have strict            infection
                              control     background,           he or she is an officer             with significant
                              prior     quality      assurance         experience      and training.          There are no
                              required      assist      visits.
                              The Air Force has identified             infection      control     as an Inspector
                              General Special         Interest   item.      Infection     control     is routinely
                              reviewed      on Health Service       Management inspections.              The mid-level
                              Staff     Assist    Group is capable of identifying             deficiencies       in an
                              infection       control    program and has direct          access to a clinical
                              consultant       at the major command level.
                                                                             -8-



                                       Page70                                                      GAO/HRD90-74DODInfectionControl
         AppendixVIl
         CommentsFromthe DepartmentofDefense




While the infection            control     consultant     for each medical         cormnand
is available       for consultation,           the Army does not have overall
guidance     that authorizes           planned and systematic          consultative
visits.     Joint      Commission survey findings             are monitored        and a
comprehensive        checklist       is updated annually,         but Army inspections
have become focused on selected                  system-wide     problems,      of which
infection      control    may be a part.           All the Services        address
infection      control    problems when deficiencies              are found.
Review of Joint        Commission survey findings                 is regularly       conducted
by the services.           However, the DOD agrees that,                 while   the
Inspector      General Teams review            infection       control    programs for the
Services,      there    is neither      Service       guidance      that requires       regular
evaluation       of infection       control      programs,      nor is there Service
guidance     for the provision          of planned and systematic               consultation
and assistance.           Accordingly,       by May 1990, the Assistant
Secretary      of Defense (Health           Affairs)      will   direct     the Services        to
conduct    planned     and systematic          reviews     of infection        control
programs.       (See also the DOD response to Recommendation                       3)




                                              -9-




         Page 71                                                  GAO/HRD90-74 DOD Infection Control
                                    Appendix W
                                    Comments From the Department of Defense




                                                               RECOMMENDATIONS

                         PECOMMENDATION 1: The GAO recommended that the Secretary                  of
                         Defense direct       the Service    Secretaries,   in conjunction     with the
                         Assistant    Secretary     of Defense for Health Affairs,         to update
                         Service   infection      control  regulations--at    a minimum, requiring
                         the regulations        to contain   components similar    to those in the
Now on pp. 4-5 and 28.   GAO-developed       basic elements.       (p. 5, p. 44 GAO Draft Report)
                         DOD ReSDOnSe:           Concur.        By May 1990, the Assistant              Secretary   of
                         Defense (Health          Affairs)       will     require    the Services       to adopt
                         infection       control     policies         that are in compliance           with current
                         Joint     Commission Standards               and those of other nationally
                         recognized       experts      as applicable.             The GAO elements        will  be
                         provided      to facilities          for their       consideration        and
                         implementation,          as appropriate.             Service     policies     are to describe
                         the level       of support        required       for the maintenance          of the program.
                         RECOMMENDATION 2: The GAO recommended that the Secretary                      of
                         Defense direct       the Service      Secretaries,    in conjunction     with the
                         Assistant     Secretary     of Defense for Health Affairs,            to (1)
                         require    the Surgeons General to determine             the relative    priority
                         of the infection        control   programs in relation        to other hospital
                         activities      and (2) assure the hospitals          provide   adequate
Now on pp. 5 and 36.     resources     to infection      control.       (p. 5, p. 57 GAO Draft Report)
                         DOD ReSDOnSe:          Concur.        Infection    prevention    and control    are
                         priorities      by virtue        of the fact that they are essential            elements
                         of quality      patient      care.       They are also a standard        of the
                         hospital      accreditation         process.     In addition     to the direction       to
                         adopt infection          control      practices    as described     in the DOD
                         response      to Recommendation            1, by May 1990 the Assistant        secretary
                         of Defense (Health           Affairs)       will direct     the Surgeons General to:
                               --    reemphasize     the importance   of infection            control    programs
                                     to quality     patient outcomes,   and
                               --    review    infection     control   programs and assets,   relative              to
                                     resources,       and take corrective     action as appropriate.
                         In addition,     the      DOD will    pursue       refinement   and implementation          of
                         automated    support       systems.
                         RECOMMENDATION 3: The GAO recommended that the Secretary                         of
                         Defense direct       the Service    Secretaries,      in conjunction         with the
                         Assistant    Secretary     of Defense for Health Affairs,            to assure that
                         headquarters     or mid-level      command staff,       who are familiar         with
                         infection    control    program activities,        make periodic       visits       to
                         each hospital      to provide    technical     assistance    to the infection
Now on pp. 5 and 37.     control   program.       (P- 5, P. 57 GAO Draft Report)
                                                                     -lO-




                                    Page72                                               GAO/HRD-90.74DODInfectionControl
-
            Appendix VII
            CommentsFrom the Department of Defense




    DOD Resaonse:       Concur.     By May 1990, the Assistant            Secretary       of
    Defense (Health      Affairs)    will     further    direct  the Services         to
    provide    for both technical         assistance     and regular     evaluation       of
    the full     scope of infection        control    programs.      This will      include
    targeting     of technical     assistance       and periodic     evaluation       of
    hospitals,     as appropriate.




                                              -ll-




           Page 73                                              GAO/HRB90-74 DDD Infection Control
Appendix VIII

Major Contributors to This Report


Human Resources        Michelle L. Roman, Assignment Manager
Division,              Eileen K. Marek, Evaluator
                       Lawrence L. Moore, Evaluator
Washington, D.C.

n                      Pamela Y. Brown, Evaluator


                       Kathleen H. Ebert, Evaluator-in-Charge
Los Angeles Regional   Aleta L. Hancock, Evaluator
Office                 Leah R. Geer, Evaluator




(101337)               Page 74                                  GAO/HRD+O-74DOD Infection Control
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