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Implementing control measures
American Journal of Infection Control Volume 9
Number 4
November 1981
ARTICLES
Implementing control measures Charles S. Bryan, M.D. Esther Deever, R.N. Columbia, S.C.
Implementation is the means by which a favorable infection control policy leads to a favorable result (low infection rate). Determination of endemic infection rates by traditional surveillance (outcome surveillance) may, in many situations, be a relatively insensitive method for identifying suboptimal implementation practices. Surveillance of the practices themselves (process surveillance) may identify situations likely to lead to unfavorable results and thus provide early feedback to personnel. Innovative approaches to process surveillance are needed in order to enhance motivation. (AM J INFECT CONTROL 9:101, 1981.)
The verb "to implement" derives from the Latin implere, which means "to fill up." In our darkest moments, we perceive infection control to be just that: filling up volumes of loose leaf binders labeled "policies"; filling up reams of reports labeled "surveillance data"; and filling up the valuable time of committee members in "meetings." The modern meanings of the verb "to implement," however, are "to carry into effect; fulfill; or accomplish" or, alternatively, "to provide the means for the carrying out of; to give practical effect to."1 In this review, we will attempt to provide a perspective on implementing (i.e., giving practical effect to) infection control measures. Implementation can be defined as the means by which an enlightened policy leads to a Presented at "Hospital Epidemiology: A Regional Program for Physicians," Association for Practitioners in Infection Control and APIC Dade County, January 8-9, 1981, Miami. Reprint requests: Charles S. Bryan, MD., Department of Medicine, University of South Carolina School of Medicine, Richland Memorial Hospital, Columbia, SC 29203. 0196-6553/81/040101+06$00.60/0
© 1981 Assoc. Pract. Infect. Control
favorable result (Fig. 1). In order to observe, to measure, and to define the various components of implementation, we must use surveillance methods that respond to both the process and the outcome of infection control. Traditional surveillance methods measure the end result of infection control-the infection rate. Much of the infection control literature deals with the methods and results of such outcome surveillance, and the value of routine outcome surveillance continues to be debated. 2 There is, however, another major type of surveillance about which relatively little has been written. This second type of surveillance is used to observe, to describe, and to measure the actual process of implementation of infection control policies. We suggest that this second type can be properly called process surveillance and that it is an essenitial part of surveillance (French surveiller, "to watch over") activities. The relationship of outcome to process surveillance is complex and dynamic (Fig. 2). An unfavorable infection rate, determined by outcome surveillance, suggests the need to im101
American Journal of
102 Bryan and Deever
INFECTION CONTROL
IMPLEMENTATION
POLICY
(PROCEDURES)
-------+~
RESULT
(INFECTION RATE)
(RULES)
Fig.1. Implementation defined (see text). IMPLEMENTATION
POLICY
•
(PROCEDURES)
-------3.~RESULT
•
(INFECTION RATE)
Fig. 2. Relationship of outcome surveillance to process surveillance (see text). Both are necessary for successful implementation of policy.
prove implementation (vector A). To improve implementation, it may be appropriate to design process surveillance methods (vector B) in order to determine how implementation might be best improved. Finally, there may be a need to modify the actual policy (vector C). Used independently, process surveillance may suggest departures from policy that necessitate outcome studies in a specific, targeted area (vector D, Fig. 2). Process surveillance may also indicate the need to reinforce specific paractices (vector E). Finally, process surveillance may suggest that current practices differ from written policy because the written policy has become outmoded and therefore needs revision (vector F). The activities that we include under the designation process surveillance will be familiar to ICPs. We suggest that surveillance itself constitutes the "control" in an infection control program. Although "control" is often equated with "enforcement," the verb "to control" has a different and more fundamental meaning. The French verb controler .has as its primary meaning "to check, test, or verify by evidence or experiments." Although both outcome surveillance and process surveillance provide such "con-
trol," process surveillance may be the more useful form of surveillance for promoting day-today implementation. Process surveillance, then, provides an ongoing system for reviewing and verifying the implementation of infection control policies. We shall examine the relationship of process surveillance to outcome surveillance in specific areas of infection control. Handwashing
Routine handwashing remains the single most important and the most frequently neglected infection control practice. Outcome surveillance, expressed as an observed infection rate, provides only indirect evidence of handwashing practices. Process surveillance such as systematic observation of personneP or culturing of hands 4 provides data of immediate instructive value. At our institution, we regularly evaluate the understanding of handwashing principles by personnel during infection control rounds. At first, we found that few personnel knew that the recommended duration for between-patient handwashing is 15 seconds. To reinforce this concept and to impart a sense of the duration of 15 seconds, we conduct" 15 second handwashing drills" during rounds (Fig. 3). A leader instructs participants to rub their hands together at the sound of a signal and to stop when they believe that 15 seconds have elapsed. On repeat visits to the units where this drill had been conducted, we found that understanding and compliance had improved. This simple drill is an example of intervention based on process surveillance (vector E, Fig. 2). Urinary catheters
Outcome surveillance reports from most hospitals indicate that infections related to indwelling urinary catheters continue to be the most frequently encountered examples of nosocomial infection. Daily bacteriologic monitoring of catheters constitutes a special form of outcome surveillance, which may help call attention to the risks associated with indwelling catheters and thus help reduce the length of catheterization. 5 Daily bacteriologic monitoring of catheters is
Volume 9 Number 4
Implementing control measures 103
November, 1981
Fig. 3. The 15-second handwashing drill (see text).
not carried out on a routine basis at our hospital. We studied prospectively 114 consecutive catheterized patients with initially sterile urine cultures and found the expected linear relationshipof significant bacteriuria to the duration of catheterization. Simultaneously, we studied the duration of catheterization in individual patients (Fig. 4). Such process surveillance of patients at risk addresses the basic question, "Does this patient really need (or still need) a catheter?" Process surveillance can also address the efficiency with which catheterized patients are separated from one another. 6 Bacteriologic monitoring of the periurethral flora, 7 if shown by ongoing studies to be useful for preventing nosocomial urinary tract infection, might constitute another example of process surveillance. Vascular access devices
Outcome surveillance results indicate that vascular access devices are the most common source of primary nosocomial bacteremia. s The extent to which primary nosocomial bacteremia can be prevented by even the strictest adherence to currently available policies has been questioned. 9 Process surveillance can define patients at risk to such infections. We have found repeatedly that the frequency with which such devices are dated at the time of insertion in-
80
NUMBER
OF PATIENTS
60
WITH
MEAN DURATION OF CATHETERIZATION=: 3.5 DAYS
CATHETER IN
40
PLACE 20
o
L-L-L-L-J_,-I --,-I--,-I--,-I--,-I----'-.1----'-.1----'-.1----'-.-1 0
2
4
6
8
10
12
14
DAYS SINCE CATHETERIZATION
Fig. 4. Determining the duration of urinary catheterization in a patient population constitutes a form of process surveillance.
creases after process surveillance has been conducted on individual wards. Process surveillance can also identify the duration of patient exposure to the device prior to removal (Fig. 5). Brown et al. lo recently determined that the extent to which personnel were familiar with the principles of vein care correlated with the observed incidence of phlebitis. Bacteriologic moni toring of all types of infusion systems related to vascular access devices may become a useful form of process surveillance, but is limited to experimental settings at this time. l1
American Journal of
104 Bryan and Deever
INFECTION CONTROL
o
PLASTIC CANNULAS
•
STAINLESS STEEL NEEDLES
o
HEPARIN LOCK DEVICES
100
PERCENTAGE OF
DEVICES REMAINING IN PLACE
begin with observations of technique, duration of surgery, traffic flow, and adherence to infection control policy within the operating room. 17 Process surveillance might also focus on the level of understanding of infection control principles among surgical staff and operating room personnel.
80
60
Isolation procedures
40 20
0
0
2
3
4
5
6
7
DAYS SINCE INSERTION
Fig. 5. Determining the duration of patient exposure to vascular access devices prior to removal constitutes a form of process surveillance. Respiratory care
Outcome surveillance led to the recogni tion of epidemic and endemic necrotizing gram-negative rod pneumonia due to contaminated respiratory therapy equipment during the 1950s and 1960s. Such epidemics have become infrequent, but endemic nosocomial pneumonia continues to be an extremely important nosocomial infectious disease problem .12. 13 Process surveillance might be a potentially useful method of identifying patients at high risk of developing nosocomial pneumonia. On the basis of a recent study,14 surveillance of the extent to which patients are being taught to turn, cough, and deep-breathe prior to surgery would be a potentially beneficial form of prevention. Bacteriologic monitoring of both respiratory therapy equipment and the tracheobronchial secretions of patients who are on respirators constitutes process surveillance. The urgent need for innovative approaches to prevention of nosocomial pneumonia has been emphasized. Ii; Wound infections
Outcome surveillance with feedback to practicing surgeons may help reduce the incidence of postoperative wound infection. 16 It is believed that most postoperative wound infections originate in the operating room. Appropriate process surveillance might therefore
Outcome surveillance has, to our knowledge, not been demonstrated to be an effective indicator of the efficiency with which hospital personnel carry out isolation policies. Process surveillance can focus on the appropriateness of isolation and the level of understanding of isolation practices among personnel. We maintain a "registry" of all patients for whom isolation is requested. The Iep reviews the appropriateness of isolation for each patient. Hyams and Ehrenkranz l8 demonstrated that attention to the appropriateness of isolation can be cost-saving to individual hospitals. Employee health
Outcome surveillance of an employee health program might include analyses of secondary cases among patients and staff. Process surveillance assumes special importance for two diseases: tuberculosis and hepatitis. We maintain "registries" of patients with these diseases as a means for monitoring the efficiency of isolation practices, the appropriateness of dispositions, and the need to institute preventive measures among exposed employees and patients. Process surveillance also includes evaluation of disease reporting by personnel and of personnel susceptibility to vaccine-preventable diseases such as rubella. SUMMARY
Recognition of nosocomial infections by outcome surveillance became a major focus for infection control during the 1960s. There is now wide agreement that point-source epidemics of nosocomi~l infection have become relatively uncommon in the United States and that most of the major unresolved problems pertain to endemic infection rates. Under the designation "process surveillance" we include many activities that are at once
Volume 9 Number 4
Implementing control measures
November, 1981
105
Table 1. Examples of process surveillance compared to outcome surveillance Area of concern
Handwashing Retention urinary catheters Vascular access devices
Respiratory care and therapy
Surgical wound care Isolation practices Hepatitis and tuberculosis
Employee health
Antibiotic review
Process surveillance
Outcome surveillance
Observations; cultures; tests of understanding; drills Observations; surveys of patients at risk; tests of understanding Surveys of dating and duration; bacteriologic monitoring; tests of understanding; observation Monitoring of equipment; surveys of patients at risk; preoperative teaching; observations Observations during surgery; surveys of dressing technique Maintenance of registry; observations; tests of understanding Maintenance of registries; evaluation of follow-up care of patients and exposed employees Reporting of diseases; efficiency with which tuberculin skin testing and rubella antibody screening are carried out; tests of understanding Evaluation of usage patterns of antibiotics; review of indications for antibiotics
familiar to infection control personnel (Table 1). Refinement of infection control policies (rules) depends largely on controlled studies done at selected institutions. Refinement of the way in which such policies are actually implemented at individual hospitals requires ongoing surveillance of the implementation process. For example, the current debate regarding the efficacy of meatal care policies for prevention of catheter-related urinary tract infections has little relevance to hospitals at which meatal care is being rendered erratically. Innovative approaches to process surveillance are needed if further reduction of endemic infection rates is to be achieved. References 1. Guralnik DB, Editor-in-Chief: Websters New World Dictionary of the American Language (Second College Edition). Cleveland, 1976, William Collins plus World Publishing Co., Inc., p. 705 2. Casewell MW: Surveillance of infection in hospitals. J Hosp Infect 1:293-297, 1980 3. Preston GA, Larson E, Stamm WE: The effect of private isolation rooms on patient care practices, colonization, and infection in an intensive care unit (ICU). Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.)
Infection rate Urinary tract infection rate; secondary bacteremias Primary bacteremia and local infection rates; incidence of phlebitis Lower respiratory tract infection rate
Wound infection rate Occurrence of secondary cases; infection rate in patients in protective isolation Occurrence of secondary cases
Occurrence of secondary cases; absenteeism from work
Recognition of antibiotic-resistant microorganisms; expenditures for antibiotics
4. Maki DG, Alvarado C, Hassemer C: A simple culture method for quantifying hand carriage of microbial pathogens in the hospital. Presented at the Second International Conference on Nosocomial Infections, Atlanta, August 5-8, 1980 (abst.) 5. Jacobson JA, Burke JP, Minton E, et al: Daily bacteriologic monitoring of urinary catheters for hospital-acquired urinary tract infections. Presented at the Second International Conference on Nosocomial Infections, Atlanta, August 5-8, 1980 (abst.) 6. Maki DG, Hennekens CH, Bennett JV: Prevention of catheter-associated urinary tract infections. An additional measure. JAMA 221:1270-1271,1972 7. Garibaldi RA, Burke JP, Britt MR, et al: Meatal colonization and catheter-associated bacteriuria. N Engl J Med 303:316-318,1980 8. Maki DG: Nosocomial bacteremia: an overview. Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.) 9. McGowan JE Jr, Parrott PL, Duty VP: Nosocomial bacteremia: potential for prevention of procedure-related cases. JAMA 237:2727-2730,1977 10. Brown BJ, Mackowiak PA, Smith JW: Care of veins during intravenous therapy: incidence of phlebitis as related to knowledge and performance. Am J Infect Control 8:107-112, 1980 11. Maki DG, Hassemer CA: Endemic rate of fluid contamination and septicemia in arterial pressure monitoring. Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.) 12. Johanson WG Jr, Pierce AK, Sanford JP, et al: Noso-
American Journal of
106 Bryan and Deever
INFECTION CONTROL
comial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 77:701-706, 1972 13. LaForce FM: Hospital-acquired lower respiratory tract infections. Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.) 14. Parker RM, Stedman BJ, Johnson JM: Prevention of postoperative respiratory infections: the importance of infection control education. Presented at the Second International Conference on Nosocomial Infections, Atlanta, August 5-8, 1980 (abst.)
15. Gross PA, Neu HC, Aswapokee P, et al: Deaths from
nosocomial infections: experience in a university hospital and a community hospital. Am J Med 68:219-223, 1980 16. Cruse PJE, Foorde R: A 5 year prospective study of 23,649 surgical wounds. Arch Surg 107:206-210, 1973 17. Hambraeus A, Laurell G: Protection of the patient in the operating suite. J Hosp Infect 1:15-30, 1980 18. Hyams PJ, Ehrenkranz NJ: The overuse of single patient isolation in hospitals. Am J Epidemiol 106:325329, 1977
Classified advertising The American Journal of Infection Control offers a classified advertising section in each issue. It lists positions available and positions desired. Rates for announcements of 30 words or less are $40.00 for one insertion and $34.00 for three or more insertions. Each additional word is $1.00 and $.85, respectively. There is a $2.50 charge for box service for the first insertion only. Payment must accompany insertion orders. Send classified ads to the Journal Advertising Department, American Journal of Infection Control, The C. V. Mosby Company, 11830 Westline Industrial Drive, SI. Louis, MO 63141.
Number 4
November 1981
ARTICLES
Implementing control measures Charles S. Bryan, M.D. Esther Deever, R.N. Columbia, S.C.
Implementation is the means by which a favorable infection control policy leads to a favorable result (low infection rate). Determination of endemic infection rates by traditional surveillance (outcome surveillance) may, in many situations, be a relatively insensitive method for identifying suboptimal implementation practices. Surveillance of the practices themselves (process surveillance) may identify situations likely to lead to unfavorable results and thus provide early feedback to personnel. Innovative approaches to process surveillance are needed in order to enhance motivation. (AM J INFECT CONTROL 9:101, 1981.)
The verb "to implement" derives from the Latin implere, which means "to fill up." In our darkest moments, we perceive infection control to be just that: filling up volumes of loose leaf binders labeled "policies"; filling up reams of reports labeled "surveillance data"; and filling up the valuable time of committee members in "meetings." The modern meanings of the verb "to implement," however, are "to carry into effect; fulfill; or accomplish" or, alternatively, "to provide the means for the carrying out of; to give practical effect to."1 In this review, we will attempt to provide a perspective on implementing (i.e., giving practical effect to) infection control measures. Implementation can be defined as the means by which an enlightened policy leads to a Presented at "Hospital Epidemiology: A Regional Program for Physicians," Association for Practitioners in Infection Control and APIC Dade County, January 8-9, 1981, Miami. Reprint requests: Charles S. Bryan, MD., Department of Medicine, University of South Carolina School of Medicine, Richland Memorial Hospital, Columbia, SC 29203. 0196-6553/81/040101+06$00.60/0
© 1981 Assoc. Pract. Infect. Control
favorable result (Fig. 1). In order to observe, to measure, and to define the various components of implementation, we must use surveillance methods that respond to both the process and the outcome of infection control. Traditional surveillance methods measure the end result of infection control-the infection rate. Much of the infection control literature deals with the methods and results of such outcome surveillance, and the value of routine outcome surveillance continues to be debated. 2 There is, however, another major type of surveillance about which relatively little has been written. This second type of surveillance is used to observe, to describe, and to measure the actual process of implementation of infection control policies. We suggest that this second type can be properly called process surveillance and that it is an essenitial part of surveillance (French surveiller, "to watch over") activities. The relationship of outcome to process surveillance is complex and dynamic (Fig. 2). An unfavorable infection rate, determined by outcome surveillance, suggests the need to im101
American Journal of
102 Bryan and Deever
INFECTION CONTROL
IMPLEMENTATION
POLICY
(PROCEDURES)
-------+~
RESULT
(INFECTION RATE)
(RULES)
Fig.1. Implementation defined (see text). IMPLEMENTATION
POLICY
•
(PROCEDURES)
-------3.~RESULT
•
(INFECTION RATE)
Fig. 2. Relationship of outcome surveillance to process surveillance (see text). Both are necessary for successful implementation of policy.
prove implementation (vector A). To improve implementation, it may be appropriate to design process surveillance methods (vector B) in order to determine how implementation might be best improved. Finally, there may be a need to modify the actual policy (vector C). Used independently, process surveillance may suggest departures from policy that necessitate outcome studies in a specific, targeted area (vector D, Fig. 2). Process surveillance may also indicate the need to reinforce specific paractices (vector E). Finally, process surveillance may suggest that current practices differ from written policy because the written policy has become outmoded and therefore needs revision (vector F). The activities that we include under the designation process surveillance will be familiar to ICPs. We suggest that surveillance itself constitutes the "control" in an infection control program. Although "control" is often equated with "enforcement," the verb "to control" has a different and more fundamental meaning. The French verb controler .has as its primary meaning "to check, test, or verify by evidence or experiments." Although both outcome surveillance and process surveillance provide such "con-
trol," process surveillance may be the more useful form of surveillance for promoting day-today implementation. Process surveillance, then, provides an ongoing system for reviewing and verifying the implementation of infection control policies. We shall examine the relationship of process surveillance to outcome surveillance in specific areas of infection control. Handwashing
Routine handwashing remains the single most important and the most frequently neglected infection control practice. Outcome surveillance, expressed as an observed infection rate, provides only indirect evidence of handwashing practices. Process surveillance such as systematic observation of personneP or culturing of hands 4 provides data of immediate instructive value. At our institution, we regularly evaluate the understanding of handwashing principles by personnel during infection control rounds. At first, we found that few personnel knew that the recommended duration for between-patient handwashing is 15 seconds. To reinforce this concept and to impart a sense of the duration of 15 seconds, we conduct" 15 second handwashing drills" during rounds (Fig. 3). A leader instructs participants to rub their hands together at the sound of a signal and to stop when they believe that 15 seconds have elapsed. On repeat visits to the units where this drill had been conducted, we found that understanding and compliance had improved. This simple drill is an example of intervention based on process surveillance (vector E, Fig. 2). Urinary catheters
Outcome surveillance reports from most hospitals indicate that infections related to indwelling urinary catheters continue to be the most frequently encountered examples of nosocomial infection. Daily bacteriologic monitoring of catheters constitutes a special form of outcome surveillance, which may help call attention to the risks associated with indwelling catheters and thus help reduce the length of catheterization. 5 Daily bacteriologic monitoring of catheters is
Volume 9 Number 4
Implementing control measures 103
November, 1981
Fig. 3. The 15-second handwashing drill (see text).
not carried out on a routine basis at our hospital. We studied prospectively 114 consecutive catheterized patients with initially sterile urine cultures and found the expected linear relationshipof significant bacteriuria to the duration of catheterization. Simultaneously, we studied the duration of catheterization in individual patients (Fig. 4). Such process surveillance of patients at risk addresses the basic question, "Does this patient really need (or still need) a catheter?" Process surveillance can also address the efficiency with which catheterized patients are separated from one another. 6 Bacteriologic monitoring of the periurethral flora, 7 if shown by ongoing studies to be useful for preventing nosocomial urinary tract infection, might constitute another example of process surveillance. Vascular access devices
Outcome surveillance results indicate that vascular access devices are the most common source of primary nosocomial bacteremia. s The extent to which primary nosocomial bacteremia can be prevented by even the strictest adherence to currently available policies has been questioned. 9 Process surveillance can define patients at risk to such infections. We have found repeatedly that the frequency with which such devices are dated at the time of insertion in-
80
NUMBER
OF PATIENTS
60
WITH
MEAN DURATION OF CATHETERIZATION=: 3.5 DAYS
CATHETER IN
40
PLACE 20
o
L-L-L-L-J_,-I --,-I--,-I--,-I--,-I----'-.1----'-.1----'-.1----'-.-1 0
2
4
6
8
10
12
14
DAYS SINCE CATHETERIZATION
Fig. 4. Determining the duration of urinary catheterization in a patient population constitutes a form of process surveillance.
creases after process surveillance has been conducted on individual wards. Process surveillance can also identify the duration of patient exposure to the device prior to removal (Fig. 5). Brown et al. lo recently determined that the extent to which personnel were familiar with the principles of vein care correlated with the observed incidence of phlebitis. Bacteriologic moni toring of all types of infusion systems related to vascular access devices may become a useful form of process surveillance, but is limited to experimental settings at this time. l1
American Journal of
104 Bryan and Deever
INFECTION CONTROL
o
PLASTIC CANNULAS
•
STAINLESS STEEL NEEDLES
o
HEPARIN LOCK DEVICES
100
PERCENTAGE OF
DEVICES REMAINING IN PLACE
begin with observations of technique, duration of surgery, traffic flow, and adherence to infection control policy within the operating room. 17 Process surveillance might also focus on the level of understanding of infection control principles among surgical staff and operating room personnel.
80
60
Isolation procedures
40 20
0
0
2
3
4
5
6
7
DAYS SINCE INSERTION
Fig. 5. Determining the duration of patient exposure to vascular access devices prior to removal constitutes a form of process surveillance. Respiratory care
Outcome surveillance led to the recogni tion of epidemic and endemic necrotizing gram-negative rod pneumonia due to contaminated respiratory therapy equipment during the 1950s and 1960s. Such epidemics have become infrequent, but endemic nosocomial pneumonia continues to be an extremely important nosocomial infectious disease problem .12. 13 Process surveillance might be a potentially useful method of identifying patients at high risk of developing nosocomial pneumonia. On the basis of a recent study,14 surveillance of the extent to which patients are being taught to turn, cough, and deep-breathe prior to surgery would be a potentially beneficial form of prevention. Bacteriologic monitoring of both respiratory therapy equipment and the tracheobronchial secretions of patients who are on respirators constitutes process surveillance. The urgent need for innovative approaches to prevention of nosocomial pneumonia has been emphasized. Ii; Wound infections
Outcome surveillance with feedback to practicing surgeons may help reduce the incidence of postoperative wound infection. 16 It is believed that most postoperative wound infections originate in the operating room. Appropriate process surveillance might therefore
Outcome surveillance has, to our knowledge, not been demonstrated to be an effective indicator of the efficiency with which hospital personnel carry out isolation policies. Process surveillance can focus on the appropriateness of isolation and the level of understanding of isolation practices among personnel. We maintain a "registry" of all patients for whom isolation is requested. The Iep reviews the appropriateness of isolation for each patient. Hyams and Ehrenkranz l8 demonstrated that attention to the appropriateness of isolation can be cost-saving to individual hospitals. Employee health
Outcome surveillance of an employee health program might include analyses of secondary cases among patients and staff. Process surveillance assumes special importance for two diseases: tuberculosis and hepatitis. We maintain "registries" of patients with these diseases as a means for monitoring the efficiency of isolation practices, the appropriateness of dispositions, and the need to institute preventive measures among exposed employees and patients. Process surveillance also includes evaluation of disease reporting by personnel and of personnel susceptibility to vaccine-preventable diseases such as rubella. SUMMARY
Recognition of nosocomial infections by outcome surveillance became a major focus for infection control during the 1960s. There is now wide agreement that point-source epidemics of nosocomi~l infection have become relatively uncommon in the United States and that most of the major unresolved problems pertain to endemic infection rates. Under the designation "process surveillance" we include many activities that are at once
Volume 9 Number 4
Implementing control measures
November, 1981
105
Table 1. Examples of process surveillance compared to outcome surveillance Area of concern
Handwashing Retention urinary catheters Vascular access devices
Respiratory care and therapy
Surgical wound care Isolation practices Hepatitis and tuberculosis
Employee health
Antibiotic review
Process surveillance
Outcome surveillance
Observations; cultures; tests of understanding; drills Observations; surveys of patients at risk; tests of understanding Surveys of dating and duration; bacteriologic monitoring; tests of understanding; observation Monitoring of equipment; surveys of patients at risk; preoperative teaching; observations Observations during surgery; surveys of dressing technique Maintenance of registry; observations; tests of understanding Maintenance of registries; evaluation of follow-up care of patients and exposed employees Reporting of diseases; efficiency with which tuberculin skin testing and rubella antibody screening are carried out; tests of understanding Evaluation of usage patterns of antibiotics; review of indications for antibiotics
familiar to infection control personnel (Table 1). Refinement of infection control policies (rules) depends largely on controlled studies done at selected institutions. Refinement of the way in which such policies are actually implemented at individual hospitals requires ongoing surveillance of the implementation process. For example, the current debate regarding the efficacy of meatal care policies for prevention of catheter-related urinary tract infections has little relevance to hospitals at which meatal care is being rendered erratically. Innovative approaches to process surveillance are needed if further reduction of endemic infection rates is to be achieved. References 1. Guralnik DB, Editor-in-Chief: Websters New World Dictionary of the American Language (Second College Edition). Cleveland, 1976, William Collins plus World Publishing Co., Inc., p. 705 2. Casewell MW: Surveillance of infection in hospitals. J Hosp Infect 1:293-297, 1980 3. Preston GA, Larson E, Stamm WE: The effect of private isolation rooms on patient care practices, colonization, and infection in an intensive care unit (ICU). Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.)
Infection rate Urinary tract infection rate; secondary bacteremias Primary bacteremia and local infection rates; incidence of phlebitis Lower respiratory tract infection rate
Wound infection rate Occurrence of secondary cases; infection rate in patients in protective isolation Occurrence of secondary cases
Occurrence of secondary cases; absenteeism from work
Recognition of antibiotic-resistant microorganisms; expenditures for antibiotics
4. Maki DG, Alvarado C, Hassemer C: A simple culture method for quantifying hand carriage of microbial pathogens in the hospital. Presented at the Second International Conference on Nosocomial Infections, Atlanta, August 5-8, 1980 (abst.) 5. Jacobson JA, Burke JP, Minton E, et al: Daily bacteriologic monitoring of urinary catheters for hospital-acquired urinary tract infections. Presented at the Second International Conference on Nosocomial Infections, Atlanta, August 5-8, 1980 (abst.) 6. Maki DG, Hennekens CH, Bennett JV: Prevention of catheter-associated urinary tract infections. An additional measure. JAMA 221:1270-1271,1972 7. Garibaldi RA, Burke JP, Britt MR, et al: Meatal colonization and catheter-associated bacteriuria. N Engl J Med 303:316-318,1980 8. Maki DG: Nosocomial bacteremia: an overview. Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.) 9. McGowan JE Jr, Parrott PL, Duty VP: Nosocomial bacteremia: potential for prevention of procedure-related cases. JAMA 237:2727-2730,1977 10. Brown BJ, Mackowiak PA, Smith JW: Care of veins during intravenous therapy: incidence of phlebitis as related to knowledge and performance. Am J Infect Control 8:107-112, 1980 11. Maki DG, Hassemer CA: Endemic rate of fluid contamination and septicemia in arterial pressure monitoring. Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.) 12. Johanson WG Jr, Pierce AK, Sanford JP, et al: Noso-
American Journal of
106 Bryan and Deever
INFECTION CONTROL
comial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 77:701-706, 1972 13. LaForce FM: Hospital-acquired lower respiratory tract infections. Presented at the Second International Conference on Nosocomial Infections, Center for Disease Control, Atlanta, August 5-8, 1980 (abst.) 14. Parker RM, Stedman BJ, Johnson JM: Prevention of postoperative respiratory infections: the importance of infection control education. Presented at the Second International Conference on Nosocomial Infections, Atlanta, August 5-8, 1980 (abst.)
15. Gross PA, Neu HC, Aswapokee P, et al: Deaths from
nosocomial infections: experience in a university hospital and a community hospital. Am J Med 68:219-223, 1980 16. Cruse PJE, Foorde R: A 5 year prospective study of 23,649 surgical wounds. Arch Surg 107:206-210, 1973 17. Hambraeus A, Laurell G: Protection of the patient in the operating suite. J Hosp Infect 1:15-30, 1980 18. Hyams PJ, Ehrenkranz NJ: The overuse of single patient isolation in hospitals. Am J Epidemiol 106:325329, 1977
Classified advertising The American Journal of Infection Control offers a classified advertising section in each issue. It lists positions available and positions desired. Rates for announcements of 30 words or less are $40.00 for one insertion and $34.00 for three or more insertions. Each additional word is $1.00 and $.85, respectively. There is a $2.50 charge for box service for the first insertion only. Payment must accompany insertion orders. Send classified ads to the Journal Advertising Department, American Journal of Infection Control, The C. V. Mosby Company, 11830 Westline Industrial Drive, SI. Louis, MO 63141.