Moving Toward Better Infection Control in Healthcare Facilities

Against the backdrop of recent infectious disease outbreaks, including the international public health threat of SARS, the U.S. healthcare community has recently taken proactive steps toward learning how to effectively identify and prevent the occurrence of deadly healthcare facility infections.

Health care associated infections constitute a significant safety risk for individuals receiving care in a variety of settings. The Centers for Disease Control and Prevention (CDC) estimates that two million people acquire an infection each year while being treated in hospitals for other illnesses or injuries, and that 90,000 people die as a result.

Newly published standards from the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), as well as CDC Guidelines, bring new focus and attention to preventing these infections.

New Standards for a New Approach

In November 2003, an expert panel of the Joint Commission released their revised standards for infection control in healthcare facilities. The JCAHO 2005 Infection Control Standards address the areas of ambulatory care, behavioral healthcare, home care, hospital laboratory and long-term care organizations. The revised standards are designed to raise awareness that health care associated infections are a national concern that can be acquired within any care, treatment or service setting. Therefore, prevention represents one of the major safety initiatives that a health care organization can undertake.

The 20-member JCAHO panel consisted of infection control practitioners, hospital epidemiologists, physicians, nurses, risk managers and healthcare professionals who were charged with both recommending enhancements to standard practices and offering insights into how the Joint Commission will better ensure that accredited organizations are in compliance with approved infection control standards.

The approved JCAHO panel standards will take effect in January 2005. A pre-publication overview of the initiative can be found on the JCAHO website at:
http://www.jcaho.org/accredited+organizations/patient+safety/infection+control/ic+index.htm

The JCAHO panel's revised standards focus on development and implementation of procedures to prevent and control infections. The approved standards require organizations to:

• Incorporate an infection control program as a major component of safety performance improvement programs
• Perform an ongoing assessment to identify the risks for the acquisition and transmission of infectious agents
• Use an epidemiological approach, including collecting and interpreting data
• Implement infection prevention and control processes
• Educate and collaborate with leaders across the organization to design and implement infection control programs

Two new developing healthcare issues have been identified since the JCAHO standards were outlined. Requirements for addressing emerging antimicrobial resistance, and managing epidemics and emerging pathogens are currently being reviewed by accreditation organizations.

The revised standards are designed to assist in the identification and reduction of risks that can lead to acquiring and transmitting infection among employees, physicians and visitors at medical healthcare facilities. The standards cover both direct patient care and those used to support patient care. The JCAHO standards will require healthcare organizations to work with local, state and federal agencies to prevent and control the introduction of infectious diseases.

CDC Guidelines Promoted to Reduce Risk of Infection

The CDC has also issued its own recommendations tool, Guidelines for Environmental Infection Control in Health Care Facilities. These guidelines are a four-part report available on the CDC's Division of Healthcare Quality Promotion website < http://www.cdc.gov/ncidod/hip/default.htm>.

In general, the report recommends:

• Adherence to proper use of disinfectants, proper maintenance of medical equipment that use water
• Water-quality standards for hemodialysis, and proper ventilation standards for specialized care environments (airborne infection isolation, protective environment, and operating rooms)
• Prompt management of water intrusion into facility structural elements to minimize healthcare-associated infection risks and reduce the frequency of outbreaks
• Conduct routine environmental sampling only when it is directed by epidemiologic principles and the results can be applied directly to infection control decisions

The CDC also has also released guidelines for hand washing in healthcare facilities. The general recommendations are as follows:

1)	Wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water when they are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids
2)	If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands
3)	Hands should be cleaned after contact with a patient's intact skin, contact with environmental surfaces in the immediate vicinity of patients and after glove removal

These CDC reports these general recommendations are promoted to minimize the risk of transmission of microorganisms to patients, minimize the potential risk of healthcare worker infection caused by organisms acquired from the patient, and reduce the mortality rates and healthcare costs associated with healthcare-associated infections.

SARS Case Study Sheds Light

In the wake of the re-emergence of SARS cases, recent policy reviews and recommendations have been offered within the healthcare community regarding infection control procedures. In the upcoming March 2004 issue of the CDC's Emerging Infectious Diseases Journal, the article, "SARS Transmission and Hospital Containment" reviews the lessons learned from the SARS outbreak in Singapore in March 2003. The recommendations provide insight into how healthcare facilities may analyze a potential outbreak situation and approach its policy on infectious disease management and spread prevention.

The study presents insight into the alternate containment strategies that were used by three different hospitals in Singapore in their efforts to contain the infection in March 2003. The strategies employed were:

1) Close the entire hospital

2) Remove all potentially infected patients to a dedicated SARS hospital

3) Manage exposed persons in place

By evaluating how the contrasting strategies in these three hospitals affected the spread of the virus, a best practices evaluation was developed supporting the position that circumstances of the individual detection will dictate the appropriate healthcare facility response to the outbreak. The journal article findings conclude that SARS is managed most effectively in early detection circumstances by 1) removing all exposed people to a designated location, or 2) isolating them and managing them in place. In late detection scenarios, however, a hospital may be more successful in disease-spread management by closing its doors to contain the spread of the disease.

With these strategies outlined, the best practices containment discipline recommendations included the following:

• Obtain contact history - Review the patient's contact history for contact with other SARS patients. Also review other areas in the hospital where they may have stayed. This should be done within 48 hours. All contacts should be quarantined or kept under medical surveillance.
• Monitor Healthcare Workers for Fever - Monitor and record the temperatures of all hospital staff three times a day. Healthcare workers with a temperature greater than 37.5°C should not be allowed to work and those with a fever for more than three days, or occurring as part of a cluster of cases, should be isolated. Also, when more than two staff members of patients in a clinical area are febrile, epidemiologic investigation should be initiated.
• Wear Personal Protective Equipment - Strict adherence to the use of personal protective equipment (N95 masks, gloves and gowns) can mitigate the spread of an outbreak
• Maintain a Visitor Log and Limit Visitors - In Singapore, at least 21 cases resulted from spread by hospital visitors to family and community contacts. A "no visitor" policy in all public hospitals was implemented in Singapore.
• Create a Hospital Preparedness Plan - Reviewing and updating response plans, as well as educating employees about the plan may help limit the spread of an illness such as SARS

An "ahead of publication" release of the Emerging Infectious Diseases Journal article can be found on the CDC website at http://www.cdc.gov/ncidod/EID/vol10no3/03-0650.htm.