Objectives
1. Describe how changes in communicable disease trends affect
hospital surveillance.
2. Identify the usefulness of electronic media and equipment in data collection
and analysis, and information technology.
3. Report the way surgical infections are detected and prevented.
4. Cite the various organizations that impact hospital infection prevention.
5. Describe the cause and effect of hospital construction/renovation on
potential hospital infections.
There's a shift in the wind and a tingle in the air as the season changes.
Autumn brings us to a field of new challenges. We are fortunate to have
new tools to meet them.
Hospital Surveillance and Public Health
The last two years have been full of changes and challenges, such
as the publication of the Health Insurance Portability and Accountability
Act (HIPAA) mandating patient privacy.1This
impacts the type and manner of information we share with individuals
within and outside of our facility. Computer and fax data, phone and
facility paper trails are now managed with HIPAA rules in mind. State
laws govern which diseases are reportable, and include time frames and
identification of the infected persons. Public health disease surveillance
identifies bioterrorism events, demonstrates trends in sexually transmitted
diseases and bloodborne pathogens, and serves as an early warning system
in detecting populations with ineffective immunity to vaccine-preventable
diseases.
Certain vaccination laws are being eased in special situations for school-age
children.2 There is some concern that non-immune
children could develop vaccine-preventable diseases and spread these
in the community. Infants, the elderly and immunocompromised persons
are at greatest risk for severe illness related to vaccine-preventable
diseases. Vaccination can greatly decrease disease as demonstrated by
the pneumococcal vaccination program. 3
Controversy exists regarding the benefit in reporting other communicable
diseases. The right and need for Public Health Department knowledge
of the identity of persons with HIV/AIDS and other sexually transmitted
diseases is a concern for some. Although HIV/AIDS is also transmitted
by other behaviors, it is still primarily transmitted by men who have
sex with men and through "street drug" use from contaminated
needles, syringes and nasal straws. Health departments use reported
data to track the spread of disease, plan age- and behavior-specific
education and prevention, and assist with treatment and support systems.
Political and religious organizations are also making both positive
and negative judgments about these high-risk behaviors. Television,
movies and magazines are influencing public attitudes regarding homosexuality
and "street drug" use. Fear of harassment, loss of employment
and housing, damaged personal relationships and loss of health insurance
are among the issues faced by those who question the mandatory reporting
laws surrounding certain communicable diseases. Many health departments
do offer HIV testing that is anonymous. The person tested is not identified
by name, address or social security number in this situation.
Although treatment plans for HIV are becoming more sophisticated, problems
remain such as resistance to medication, failure to take medications
due to side effects and cost, and denial of disease. Some wonder if
HIV will again increase as when it was first identified.
Syphilis among men who have sex with men is also on the rise around
the world and in the United States.4 We
assure appropriate treatment and report required data to the health
department. States may be considering a change of current laws that
would then allow physicians to prescribe treatment to partners of infected
individuals, without seeing them in the office. Treatment failures due
to noncompliance or from physicians' incomplete access to final lab
values before treatment could cause relapse and even development of
resistance to medication. Emergency room and infection surveillance
staff work together to identify results confirmatory for syphilis, and
assure appropriate education and treatment. Syphilis is also a disease
that can be acquired through sexual practices, from mother to infant
during birth and as a bloodborne pathogen through sharing contaminated
"street drug" equipment.
Bloodborne pathogen exposure is also a public health challenge for emergency
room and infection surveillance staff who assist public health workers
with the management of inadvertent, unprotected exposure to blood and
body fluids in the line of duty. First responders may present to the
emergency room requesting testing of the person who bled into the first
responders' cut skin, or who bit them. They might request a baseline
testing for themselves. If, when and how to test and report results,
and who to bill for payment, are questions not completely answered for
every county and district by state laws. Your Association For Practitioners
in Infection Control and Epidemiology (APIC) Committee may guide you
in this process. State regulations are sometimes published online.5
Your local public health departments may be the middleman for receiving
lab reports regarding exposures and informing exposed persons of the
results.
Patients and staff with communicable diseases require appropriate management
to prevent disease spread. The Centers for Disease Control and Prevention
(CDC) 1997 Guideline for Isolation Precautions in Hospitals, the 1998
Guidelines for Infection Control in Hospitals, and the Guideline for
Environmental Infection Control in Health Care help determine the prevention,
detection and surveillance needed to manage communicable disease within
the facility and community. The APIC text also leads the infection surveillance
team in understanding current practice and standards in prevention of
the spread of disease.
Effective surveillance requires a knowledge of the air, water and building
structure of your facility. The 2003 Guideline for Environmental Infection
Control in Health Care Facilities reflects standards and tools for planning
and surveillance surrounding construction and renovation, and general
facility environmental issues. The infection surveillance team must
know the location of negative air pressure rooms, the air exchange rate
for special procedure rooms and the way the plant operations department
assures the proper working order of the water lines, heat and air systems
and maintenance and repair of equipment in general and for emergent
conditions. Air, water, ceilings, water pipes and floors harbor microorganisms
that escape when disturbed by everyday use or from changes in the facility.
Environment of Care (EOC)
EOC rounds can be an effective patient safety tool. On-the-spot identification
and resolution of problems with equipment, the building, processes and
knowledge gaps can prevent patient injury and promote health. The EOC
team of managers, plant operations, risk infection control and nursing
staff use a planned inspection list, rounding on specific units on specific
dates. Results are forwarded to departments and monitored for resolution.
Employee Health and Safety
The Occupational Safety and Health Administration (OSHA) protects healthcare
workers from exposure to harm in the workplace. Bloodborne pathogen
exposure prevention plans utilize data-driven expectations for improved
work practices and environmental controls. It is important to collect
accurate data regarding how an exposure occurs to identify ways to prevent
further exposures. The updated OSHA Bloodborne Pathogen (BBP) Exposure
Prevention Plan requires facilities to educate staff and provide working
conditions and equipment that avoid injury from sharp equipment. Sharps
safety devices must be available and used. Employees must trial equipment
for improved safety where potential for exposures occur. Infection Control,
Employee Health, Risk, Safety and Quality work with nursing and allied
health to identify job classifications, procedures and equipment that
could place staff at risk for exposure to BBPs. Improvements are tracked
to determine successful safety measures.
Recent smallpox vaccination efforts by the public health system further
promoted employee safety. Emergency response team volunteers were educated
and offered the smallpox vaccination to prepare staff to safely care
for any smallpox patient who might present to the facility.
Bioterrorism
Bioterrorism concerns have forced an increased awareness of trends and
patterns of illness observed in patients in emergency rooms, short-stay
areas and diagnostic departments. Computer-driven reports of daily census
with diagnosis and symptoms, as well as review of abnormal lab values,
can assist the infection surveillance team in identifying unusual or
increased numbers of illness. Publications such as the Bio-Terry Book
(6), Health Security and Emergency Management, and online education
offered by Digiscript, CDC's Public Health Training Network (PHTN),
your local APIC bioterrorism plan and your facility plan will help guide
you in readiness for a bioterrorism event. Surveillance for bioterrorism
includes good communication with public health departments, facility
leadership and direct patient caregivers and the media. Follow the advice
of your public relations and safety staff in managing surveillance data
to avoid creating panic among staff and the public. Routinely review
your written plan and update names, phone and fax numbers and assigned
responsibilities.
States may soon be requiring continuing education for nurses with specific
bioterrorism contents. Surveillance teams may be requested to assist
in ongoing training. Public Health and Quality/Safety initiatives could
offer assistance with courses along this line. The CDC and Digiscript
Internet site have made courses available for SARS (severe acute respiratory
syndrome), smallpox, monkeypox and bioterrorism. Surveillance for adverse
reactions to vaccination against agents of bioterrorism requires specialized
training and reporting. Also, as our citizens and military return from
service in other countries, we may see new and unusual syndromes and
diseases in our surveillance. We work closely with our Infectious Disease
physicians and health departments to keep the lines of communication
open.
Targeted Surveillance
Infection surveillance observes for unusual or increased infection rates.
Collected information is used in planning prevention and detection of
infectious disease. Surveillance focuses on high-risk, high-volume and
problem-prone surgical procedures and equipment. Computer systems tied
to surgical risk data along with information from lab results and chart
reviews, as well as infection reports from staff, assist us in identifying
nosocomial infections.
Benchmarking infection rates helps predict and prevent infections. We
use the NNIS (National Nosocomial Infections System) to benchmark our
rates.7 Certain hospitals volunteer to
use strict criteria to collect data on infections in specific surgeries
and stratify them into risk categories. Risk categories include the
ASA (American Society of Anesthesia) rating, which looks at conditions
such as diabetes and other health history, and whether the surgical
area is clean, contaminated or dirty at the time of the incision. Infection
rates are tabulated, then compared by like facilities to trend year-by-year
for improvements. National and peer groups also research and develop
plans for improved patient outcomes.
Online access is available for current and archived data for groups
such as the Association of Operating Room Nurses (AORN), the CDC, the
Agency for Healthcare Research and Quality (AHRQ), The Joint Commission
of the American Hospital Association (JCAHO), the Institute of Medicine
(IOM), the Infectious Disease Society (IDS) and the APIC Text of Infection
Control and Hospital Epidemiology.
Patient safety and quality goals 8 help
guide us toward best practices such as appropriate management of invasive
devices, such as catheters inserted into sterile body sites, dialysis
equipment, surgical instruments, the management of endoscopes, bronchoscopes
and vaginal probes and laser therapy. Antisepsis, cleaning, disinfection
and sterilization are important in assuring the prevention of nosocomial
infections. Following current standards and assuring staff training
and compliance to infection control processes can help prevent the transfer
of infectious diseases to patients during procedures.
Handwashing is still the best way to prevent the spread of infections.
The new CDC Guideline for Hand Hygiene in Health Care Settings 9
demonstrates the effectiveness of alcohol-based hand hygiene products
with emollients in preventing infection. Safety issues surrounding the
placement and storage of the containers of these products is under review
by fire and safety organizations. You can find updates on this subject
at the APIC website. 10 Soap and water
should be used when hands are visibly soiled. Since alcohol may not
be effective against spores, hands should be washed in soap and water
in the potential presence of Clostridium difficile and Bacillus
anthracis.
Increasing multi-drug resistant organisms (MDRs) challenge antibiotic
management and increase the cost of patient care. Patient isolation
practices (when?, why?, how?) have come under increasing scrutiny. Surveillance
for MDRs is done to assure that planned isolation is continued to prevent
the spread of these organisms.
Effective practice requires observation of hospital and community trends
in resistance patterns using antibiograms, line graphs depicting the
percentage of certain antibiotics to which certain microorganisms are
sensitive. Antibiograms can be compared over time to observe for changes
in microbial sensitivity to commonly used antibiotics. Some hospitals
develop plans to restrict the use of certain antibiotics to decrease
resistance patterns. Combining management of pharmacologicals with planned
isolation has been shown to reduce the cost of patient care and such
patterns.
Education and Communication
Surveillance can identify a need for change in planning, education and
training, processes and communication. Surveillance also identifies
successful practice as seen with improved infection rates and successful
patient outcomes. New electronic systems assist in communicating data
and analysis.
The Internet is also an effective source for obtaining information.
APIC local and national chapter websites 11
identify successful practices and offer resources for problem solving
and future topics that will impact infection control. Listservs offer
discussions and summaries regarding issues of concern, interest and
need, as well as search engines and archives of prior discussions. These
are often free and require registration to begin use. The APIC listserv
offers a digest of cumulative discussions or a line listing as each
is posted to the list. A list of directions for use usually accompanies
the first posting from the listserv once the user has registered.
Other sources for information include The Morbidity and Mortality Weekly
Report (MMWR), Immunization News, the Food and Drug Administration (FDA),
Infection Control Today, Hospital Infection Control, Infection Control
and Prevention Across the Continuum of Care (ICReport), Medscape/Medline,
the Agency for HealthCare Research and and Quality (AHRQ), Premier-Safety-Share
and many others. Journals such as the American Journal of Infection
Control (AJIC), Infection Control and Hospital Epidemiology (ICHE),
The New England Journal of Medicine (NEJM), the Journal of the American
Medical Association (JAMA) and others are extremely helpful to the infection
surveillance team.
Vendors, too, can be a valuable source of knowledge. They can provide
information about new products, variations in market trends, and future
products planned. They provide manufacturer's guidelines for product
use, decontamination, maintenance, cleaning and repair. Often they provide
references to community standards for the procedures for which they
are used. Vendors can assist with troubleshooting and prevention of
problems. A file of products used, reference personnel, and a list of
when and where new products were trialed and are used may assist in
tracking equipment success and problems with use.
Conclusion
The challenging changes we have seen in hospitals affecting surveillance
can bring extremely rewarding results. Prescription for success: 1)
Support your infection surveillance team. 2) Utilize the myriad
of tools available. 3) Develop proficiency with laptops, handhelds
and PowerPoint equipment. 4) Continue to learn and share your
knowledge with others. Participate in conferences, in-services and committee.
We are thankful for this season of change and the bountiful information
and technology available to ensure effective hospital surveillance.
References
1. The Health Insurance and Portability Act of 1996 Title 45, Code of
Federal Standards. Texas Department web message: http://www.tdh.state.tx.us/hipaa/webmessage.htm
2. Texas Department of Health: Texas House Bill 2292 http://www.tdh.state.tx/immunize/school_exclusion.htm
3. Immunization News: "Childhood Vaccine a Powerful Germ Fighter,
CDC Finds" Chicago Tribune (www.chicagotribune.com)
(9/18/03) P. C14; Kotulak, Ronald.
4. Bergman S. Resurgence of syphilis in the United States. Program Abstracts
of the 15th Annual Meeting of the International Society of Sexually
Transmitted Disease Research: July 27-30, 2003: Ottawa, Ontario, Canada.
Abstract 314.
5. Texas Safety and Health Code 81.948 Notification of Emergency Personnel,
Peace Officers and Fire Fighters.
6. Bio-Terry Paul Rega, M.D. F.A.C.E.P. May 2001.
7. Am J Infection Control 2002:30; 458-75 National Nosocomial Infections
Surveillance System http://www.cdc.gov/ncidod/hip/NNIS@NNIS.htm
8. Evidence Report Technology Assessment No. 43, Making Health Care
Safer: A Critical Analysis of Patient Safety Practices (AHRQ Publication
No. 01-058) http://www.ahrq.gov/clinic/ptsafety/summary/htm
9. Guideline for Hand Hygiene in Health-Care Settings Morbidity and
Mortality Weekly Report, Recommendations and Reports October 25, 2002/Vol.
51/ No. RR-16
10. The Association for Practitioners in Infection Control and Epidemiology
Website http://www.apic.org
11. The Association for Practitioner in Infection Control and Epidemiology
Dallas-Fort Worth Chapter Website
http://www.apicdfw.ogr
