Status of infection surveillance and control programs in the United States, 1992-1996

ARTICLES Status of infection surveillance and control programs in the United States, 1992-1996 Giang T. Nguyêñ, MD, MPHa Suzanne E. Proctor, BAa Ronda L. Sinkowitz-Cochran, MPHa Denise O. Garrett, MDa William R. Jarvis, MDa Association for Professionals in Infection Control and Epidemiology, Incb Atlanta, Georgia, and Washington, DC

Background: Nosocomial infections have been recognized as a source of morbidity and mortality throughout the world for several decades. In the United States, an estimated 2.1 million nosocomial infections occur annually in acute care hospitals alone. Infection surveillance and control programs (ISCPs) play a vital role in addressing this problem, but no national studies have described the status and composition of these programs since the 1970s. Methods: In January 1997, a voluntary survey was sent by mail to members of the Association for Professionals in Infection Control and Epidemiology, Inc. Only one response per facility was requested. The survey asked for information for the years 1992 to 1996 (study period), and questions pertained to characteristics of the health care facility in which the respondent worked, characteristics of the ISCP and its personnel, and the overall level of administration support for infection control activities. Results: Completed questionnaires were received from personnel at 187 health care facilities located in 40 states and the District of Columbia. The majority (76.5%) of responding facilities were nongovernment owned, and 57.2% were classified as general acute care facilities. The number of licensed beds at these facilities remained stable throughout the study period, but all other measures of facility size and activity (eg, number of patient days and number of nurses) decreased by as much as 28.9%. In 1992, ISCPs were most likely to be organizationally located in the Nursing Department, but by 1996, many had been transferred to departments of Medical Records, Quality Assurance, or Risk Management. Throughout the course of the study period, the number of facilities performing surveillance for health care–associated infections in outpatient settings increased by 44.0%, from 100 to 144. In 1996, only 47.6% of facilities had a hospital epidemiologist (HE), and HEs devoted a median of 15% or less of their time to infection control activities. For the most part, HEs were trained in infectious diseases, and few had certification in infection control. Infection control professionals (ICPs) were much more common than were HEs (ICPs were reported at 97.9% of respondents’ facilities in 1996), and they spent the majority (80% in 1996) of their time on infection control activities. During the course of the study period, increasing numbers of facilities had ICPs who had certification in infection control. Furthermore, most respondents did not report a change over time in the level of administration support for infection control activities. Conclusions: Health care delivery has changed dramatically during the past 20 years. This study presents an updated description of ISCPs in the United States. Our results illustrate several changing parameters, such as departmental shifts and increased outpatient surveillance, that reflect adjustments in health care priorities during the study period. As the transformation of the health care system continues, continued evaluation of the status of ISCPs on a national level will be necessary. Diligent monitoring, proactive measures, and collaboration between infection control organizations and government agencies will be vital for the prevention and control of health care–associated infections in the future. (AJIC Am J Infect Control 2000;28:392-400)

From the Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, United States Department of Health and Human Services, Atlanta,a and the Association for Professionals in Infection Control and Epidemiology, Inc, Washington, DC.b Reprint requests: Ronda L. Sinkowitz-Cochran, MPH, Hospital Infections Program, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E69, Atlanta, GA 30333. Copyright © 2000 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2000/$12.00 + 0 doi:10.1067/mic.2000.110298

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Nosocomial infections have been recognized as a source of morbidity and mortality throughout the world.1-6 According to the Institute of Medicine, preventable adverse patient events, including nosocomial infections, are responsible for 44,000 to 98,000 deaths annually and cost $17 billion to $29 billion.7 Most commonly, nosocomial infections present as pneumonia, surgical site infections, urinary tract infections, and sepsis.8 Patients in intensive care units (ICUs), surgical centers, medical services, burn units, or neonatal ICUs are particularly at increased risk of nosocomial infection.9

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In the United States, an estimated 2.1 million nosocomial infections occur annually in acute care hospitals alone; if other settings, such as nursing homes, also are considered, this figure may be as high as 4 million.10 In an age of prospective payment based on diagnosis-related groups, health care facilities lose from $583 to $4886 for every nosocomial infection.8 In the past 2 decades, we have witnessed the re-emergence of nosocomial Mycobacterium tuberculosis infection and the emergence of antimicrobial-resistant pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci; these infections add substantially to morbidity, mortality, and increased health care expenditures.9,11,12 In the 1960s, driven largely by the alarming number of staphylococcal infections in the United States, the Centers for Disease Control and Prevention began recommending that hospitals conduct surveillance of nosocomial infections. During the next 2 decades, infection surveillance and control programs (ISCPs) were established in most hospitals in the United States.13 In 1974, the Centers for Disease Control and Prevention initiated the Study on the Efficacy of Nosocomial Infection Control (SENIC) Project as a response to the frustration felt by many professionals in infection control, who were faced with the challenge of having to justify their existence to hospital administrations.14 In addition to describing the characteristics of ISCPs and their personnel, the SENIC Project demonstrated that the level of attention paid to infection control practices was associated with the degree to which nosocomial infection rates were reduced.13,15-20 After the SENIC project, no published studies have described the status of infection control programs on a national level in the United States. In the 20 years that have elapsed, the health care milieu has changed dramatically, and like all health care providers, professionals in infection control are dealing with constant alterations in their working environment as the systems evolve around them. Therefore, in collaboration with the Association for Professionals in Infection Control and Epidemiology, Inc (APIC), we conducted a survey to establish the current status of ISCPs in United States health care facilities. METHODS In January 1997, APIC personnel mailed a survey (as part of APIC News) to their members in the United States. The cover letter requested that only one questionnaire be returned from each health care facility. The 2-page survey asked for information for the years 1992 to 1996 (study period). Preliminary questions focused on the characteristics of the health care facility, including geographic

location, type of ownership, type of facility (ie, general acute care, transitional care, children’s care, chronic care, or other), and measures of health care facility size and activity (number of beds, number of nurses, number of admissions, number of patient-days, average daily census, number of patient-days in the ICU, and number of surgical procedures). In addition, general characteristics of the ISCP were requested (eg, department in which the ISCP is located, who supervises the program, use of an indicator measurement system such as the National Nosocomial Infection Surveillance [NNIS] system, and surveillance in outpatient settings). The survey also inquired about the presence and characteristics of hospital epidemiologists (HEs), infection control professionals (ICPs), and ISCP support staff. An HE was defined as a person with an MD or PhD with special interest or expertise in hospital epidemiology and infection control. An ICP was defined as a person, besides the HE, responsible for the management and day-to-day activities of the ISCP, with or without certification in infection control. Support staff members were defined as persons who provide secretarial or computer support to the ISCP. Respondents were asked to provide information regarding financial remuneration of HEs, training and certification of HEs and ICPs, and percentage of time spent by HEs and ICPs for surveillance, in-service education, other infection control activities, employee health, and other non–infection control activities. Finally, ratings for the health care facility administration’s support of ISCP activities during the 5-year study period were requested, by using a scale of 1 (poor) to 5 (excellent). Completed surveys were entered into a computer database by using Epi-Info version 6.021 and analyzed by using PC SAS version 6.12.22 Unless otherwise noted, all rates are reported as percentage of total respondents, and continuous variables are reported as median values. Percentage change over time was calculated for all measures of health care facility size and activity during the study period. RESULTS General characteristics of responding health care facilities We received 187 completed questionnaires from health care facilities located in 40 states and the District of Columbia. These facilities accounted for more than 1 million admissions annually. The states with the largest number of respondents were California (n = 16), Texas (n = 10), Ohio (n = 9), and Pennsylvania (n = 9). Most respondents’ health care facilities were acute care facilities that were nongovernment owned, either nonprofit, or for-profit (Table 1).

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The respondents’ health care facilities ranged in size from 20 to 1625 licensed beds in 1992, with a median of 226 (Table 2). The median number of licensed beds at these facilities decreased 2.7% during the study period. Further, other measures of facility size and activity also decreased (Table 2). During the study period, the median number of nurses decreased by 25.8%. The number of admissions decreased by 12.6%, the number of patient-days per year decreased by 28.9%, and the average daily census decreased by 24.0%. The number of ICU patientdays decreased by 21.3%, and surgical procedures declined by 13.8%.

Risk Management (MQR; 50, 26.7%) (Table 3). ISCPs were much less likely to be housed within the Infectious Diseases Department (6, 3.2%). Some ISCPs (4, 2.1%) were located in multiple departments. Thirty-three (17.6%) ISCPs were located in other departments (eg, Administration, independent Infection Control Department, and Laboratory Department). During the study period, the number of ISCPs located in Nursing Departments decreased to 64 (34.2%), and those in MQR (63, 33.7%) and other departments (46, 24.6%) increased. Changes also were noted in the person responsible for supervising the ISCP (Table 3). In 1992, the director of nursing was most common (48, 25.7%), followed by the director of MQR (35, 18.7%). By 1996, these had reversed, with the MQR director supervising 41 (21.9%) programs, and the director of nursing supervising 35 (18.7%) programs. Throughout the study period, some respondents noted that they were supervised by more than one person (for example, one ISCP reported to the HE for medical issues and to the director of nursing for administrative issues and budget). Other supervisors (47, 25.1%, in 1996) included an ICP, vice president of nursing, and other administrators. The number of facility respondents who reported health care–associated infection surveillance in one or more outpatient settings increased during the course of the study period (Table 3). In 1992, 75 (40.1%) respondents reported that they performed surveillance in an ambulatory care setting; by 1996, this number had increased to 117 (62.6%). Surveillance in the home care therapy setting increased from 22 facilities (11.8%) in 1992 to 71 (38.0%) in 1996. Surveillance in long-term care and other outpatient settings (eg, dialysis center, mental health facility, and rehabilitation facility) also increased during the study period.

General characteristics of ISCPs

Characteristics of HEs

Fewer than 3 out of 10 health care facility respondents reported use of an indicator measurement system for nosocomial infection surveillance (52, 27.8%). Among facilities that use an indicator system, 24 (46.2%) used the NNIS system, 20 (38.5%) used the Maryland Hospital System, and 1 (1.9%) used both NNIS and the Maryland Hospital System. Other indicators (5, 9.6%) included systems from other states. Two (3.8%) facilities did not report the name of the indicator used. At the beginning of the study period (1992), the most likely organizational location for an ISCP was the Nursing Department (90 facilities, 48.1%), followed by departments of Medical Records, Quality Assurance, or

In 1992, 110 (58.8%) health care facility respondents did not report having an HE, and among the 77 facilities that had HEs, 51 reported only part-time HEs (Table 4). The number of respondent health care facilities with full-time, part-time, and both full- and part-time HEs remained fairly stable throughout the study period, although a slight increase was noted by 1996. Among facilities with any HEs, between 1 to 3 full-time HEs and 1 to 4 part-time HEs were reported; no facilities reported more than 4 HEs of any type. In 1992, 51 (66.2% of those who had HEs) facilities provided financial compensation to HEs specifically for their work in infection control; by 1996, this number had not changed markedly (59, 66.3%) (Table 5).

Table 1. Characteristics of respondents’ health care facilities, 1996 (N = 187) Characteristic

Ownership of facility Nongovernment nonprofit Nongovernment for-profit Local government State government Federal government Unspecified Type of facility General acute care Multiple classifications* Chronic care Children’s care Other†

No.

Percentage

110

58.8

33

17.6

18 15 8

9.6 8.0 4.3

3

1.6

107

57.2

46

24.6

5 3 26

2.7 1.6 13.9

*Combinations of classification types, including general acute care, chronic care, children’s care, transitional care, and others. †Other classification (eg, mental health, long-term care, and rehabilitation).

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Table 2. Size and activity of respondents’ health care facility, 1992-1996 (N = 187) Year Measurement (median)

Size of facility No. of licensed beds No. of nurses No. of admissions No. of patient days Average daily census No. of ICU patient days No. of surgical procedures

1992

1993

1994

1995

1996

226 291 7393 57,183 167 4471 6184

225 260 7030 52,043 150 3997 5642

226 260 6570 49,483 142 3984 5640

225 246 6523 45,664 130 3870 5359

220 216 6465 40,635 127 3517 5332

Table 3. Characteristics of ISCPs, 1992-1996 (N = 187) Year Characteristic No. (%) facilities

1992

1993

1994

1995

1996

Organizational location of ISCP Nursing MQR Infectious diseases Multiple departments Other Unspecified

90 50 6 4 33 4

(48.1) (26.7) (3.2) (2.1) (17.6) (2.1)

86 56 7 3 31 4

(46.0) (29.9) (3.7) (1.6) (16.6) (2.1)

82 58 7 5 33 2

(43.9) (31.0) (3.7) (2.7) (17.6) (1.1)

77 58 7 5 39 1

(41.2) (31.0) (3.7) (2.7) (20.9) (0.5)

64 63 6 6 46 2

(34.2) (33.7) (3.2) (3.2) (24.6) (1.1)

Person supervising ISCP activities Director of nursing Director of MQR Hospital epidemiologist Multiple supervisors Director of pathology Other Unspecified

48 35 32 16 14 35 7

(25.7) (18.7) (17.1) (8.6) (7.5) (18.7) (3.7)

46 39 30 15 15 35 7

(24.6) (20.9) (16.0) (8.0) (8.0) (18.7) (3.7)

43 39 30 16 15 39 5

(23.0) (20.9) (16.0) (8.6) (8.0) (20.9) (2.7)

42 38 33 16 11 44 3

(22.5) (20.3) (17.6) (8.6) (5.9) (23.5) (1.6)

35 41 32 17 11 47 4

(18.7) (21.9) (17.1) (9.1) (5.9) (25.1) (2.1)

Surveillance for health care– associated infections in outpatient settings* Overall (≥1 outpatient setting) Ambulatory care Long-term care Home care therapy Other

100 75 38 22 14

(53.5) (40.1) (20.3) (11.8) (7.5)

107 81 42 25 16

(57.2) (43.3) (22.5) (13.4) (8.6)

118 90 47 36 19

(63.1) (48.1) (25.1) (19.3) (10.2)

138 109 53 57 26

(73.8) (58.3) (28.3) (30.5) (13.9)

144 117 53 71 27

(77.0) (62.6) (28.3) (38.0) (14.4)

*Some respondents’ facilities performed surveillance in more than one outpatient setting; therefore, percent values do not total 100%.

The majority of facilities with HEs had persons with MDs or PhDs who were trained in infectious diseases (in 1996, this accounted for 67 facilities, or 75.3%) (Table 5). Fewer facilities (20, 22.5%, in 1996) reported having HEs with an MD or PhD trained in infection control, an MD or PhD trained in both infection control and infectious diseases, an MD or PhD trained in other fields (eg, pathology and internal medicine), or other training. Very few respondents had an HE who was certified in infection control (CIC).

HEs spent the majority of their time (median 90% in 1992-1994 and 84% in 1995-1996) on clinical practice and other non–infection control activities (Table 5). They spent 5% of their time or less on surveillance, infection control in-service education, other infection control activities, and employee health. Characteristics of ICPs Respondents’ health care facilities were more likely to report having ICPs than HEs, and these ICPs were likely to be employed full time (Table 4). In 1992, 95 (50.8%)

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Table 4. Respondent ISCP personnel by year and type, 1992-1996 (N = 187) Year Personnel type No. (%) facilities

HEs Full time only Part time only Full time and part time Neither ICPs Full time only Part time only Full time and part time Neither Support staff Full time only Part time only Full time and part time Neither

1992

1993

1994

1995

1996

24 51 2 110

(12.8) (27.3) (1.1) (58.8)

22 53 2 110

(11.8) (28.3) (1.1) (58.8)

24 57 2 104

(12.8) (30.5) (1.1) (55.6)

29 59 2 97

(15.5) (31.6) (1.1) (51.9)

29 58 2 98

(15.5) (31.0) (1.1) (52.4)

95 70 14 8

(50.8) (37.4) (7.5) (4.3)

94 70 15 8

(50.3) (37.4) (8.0) (4.3)

99 68 15 5

(52.9) (36.4) (8.0) (2.7)

91 72 19 5

(48.7) (38.5) (10.2) (2.7)

96 70 17 4

(51.3) (37.4) (9.1) (2.1)

32 70 4 81

(17.1) (37.4) (2.1) (43.3)

30 72 5 80

(16.0) (38.5) (2.7) (42.8)

34 69 8 76

(18.2) (36.9) (4.3) (40.6)

31 78 10 68

(16.6) (41.7) (5.3) (36.4)

31 74 10 72

(16.6) (39.6) (5.3) (38.5)

Table 5. Facilities with and characteristics of HEs, 1992-1996 Year Characteristic

Number of respondents Number (%) of facilities remunerating an HE for infection control activities Number (%) of facilities employing an HE with the following educational training MD or PhD with training in infectious diseases MD or PhD with other training MD or PhD with training in infection control MD or PhD with training in infectious diseases and infection control Other (eg, RN, MD with unspecified training) Unspecified Number (%) of facilities employing an HE with CIC Number of respondents Distribution of HE time, median percentage of total time* Surveillance activities Infection control in-service education Other infection control activities Employee health Other non–infection control activities

1992

77

1993

77

1994

83

1995

90

1996

89

51 (66.2)

51 (66.2)

56 (67.5)

60 (66.7)

59 (66.3)

58 (75.3) 7 (9.1)

58 (75.3) 7 (9.1)

61 (73.5) 8 (9.6)

67 (74.4) 7 (7.8)

67 (75.3) 5 (5.6)

4 (5.2)

4 (5.2)

6 (7.2)

6 (6.7)

8 (9.0)

3 (3.9)

3 (3.9)

3 (3.6)

4 (4.4)

4 (4.5)

3 (3.9) 2 (2.6)

3 (3.9) 2 (2.6)

3 (3.6) 2 (2.4)

3 (3.3) 3 (3.3)

3 (3.4) 2 (2.2)

5 (6.5) 54

5 (6.5) 52

5 (6.0) 60

6 (6.7) 65

6 (6.7) 71

3 1 3 1 90

3 1 3 1 90

4 1 4 1 90

5 1 5 1 84

5 2 5 1 84

*Median percentages reported; therefore, values do not total 100%.

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Table 6. Facilities with and characteristics of ICPs, 1992-1996 Year Characteristic

Number of respondents Number (%) of facilities employing ICPs with the following educational training RN only MPH only MT only RN and MPH RN and MT RN and other MPH and MT RN, MPH, and MT RN, MPH, and other Other Unspecified Number (%) of facilities employing ICPs with CIC Number of respondents Distribution of ICP time, median percentage of total time* Surveillance activities Infection control in-service education Other infection control activities Employee health Other non–infection control activities

1992

179

130 1 9 5 8 17 0 1 1 3 4

(72.6) (0.6) (5.0) (2.8) (4.5) (9.5) (0.0) (0.6) (0.6) (1.7) (2.2)

83 (46.4) 128

40 15 15 10 5

1993

179

129 1 9 6 8 17 0 2 1 3 3

(72.1) (0.6) (5.0) (3.4) (4.5) (9.5) (0.0) (1.1) (0.6) (1.7) (1.7)

84 (46.9) 133

40 15 15 10 8

1994

182

129 0 9 7 9 16 1 2 1 3 5

(70.9) (0.0) (4.9) (3.8) (4.9) (8.8) (0.5) (1.1) (0.5) (1.6) (2.7)

87 (47.8) 136

35 15 15 10 5

1995

182

124 1 10 6 9 19 1 2 1 6 3

(68.1) (0.5) (5.5) (3.3) (4.9) (10.4) (0.5) (1.1) (0.5) (3.3) (1.6)

111 (61.0) 139

35 15 20 10 10

1996

183

127 2 10 4 7 20 1 2 0 7 3

(69.4) (1.1) (5.5) (2.2) (3.8) (10.9) (0.5) (1.1) (0.0) (3.8) (1.6)

121 (66.1) 159

35 15 15 10 10

*Median percentages reported; therefore, values do not total 100%.

facilities had only full-time ICPs, 70 (37.4%) had only part-time ICPs, and 14 (7.5%) had more than one ICP with some employed full time and some part time. These figures did not change appreciably during the study period. In facilities with an ICP, between 1 to 8 full-time ICPs and 1 to 3 part-time ICPs were employed. Among facilities with any ICPs, most had ICPs who had RN degrees with no additional degrees (127, 69.4%, in 1996; Table 6). The remaining facilities either did not specify the training of their ICPs or reported having ICPs with training other than, or in addition to, the RN degree. The number of facilities reporting at least one ICP with CIC increased during the study period, from 83 (46.4% of facilities with ICPs) in 1992 to 121 (66.1%) in 1996 (Table 6). Whereas the majority of respondents who had CIC-designated ICPs had only one such employee, one respondent’s health care facility had 6 CIC ICPs. Most health care facilities with ICPs reported that their ICPs had attended infection control courses (147, 80.3%). Many also reported that they had ICPs who had received on-the-job training (128, 69.9%). Fifteen

(8.2%) respondents had ICPs who had received no specific training in infection control. During the study period, ICPs spent a median of 35% to 40% of their time performing surveillance activities, 15% working on infection control in-service education, 15% to 20% on other infection control activities, 10% on employee health issues, and 5% to 10% on other non–infection control activities. These values were stable over time (Table 6). Additional measures of administrative support Support staff were available to ISCPs at slightly more than half of the respondents’ health care facilities, and only minor changes were observed during the study period (Table 4). In 1996, 31 (16.6%) had full-time support staff, 74 (39.6%) had part-time support staff, 10 (5.3%) had both full-time and part-time support staff, and 72 (38.5%) reported no support staff at all. Among those responding with any support staff, between 1 to 6 full-time employees and 1 to 8 part-time employees were reported. Respondents were asked to evaluate the yearly level of support from their facilities’ administrations for infection control activities on a scale of 1 to 5 (with 5

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398 Nguyêñ et al being most supportive). In 1996, 55 respondents (29.4%) gave a rating of 5, 44 (23.5%) gave a rating of 4, 46 (24.6%) gave a rating of 3, 16 (8.6%) gave a rating of 2, and 11 (5.9%) gave a rating of 1. Fifteen (8.0%) did not respond to this question. The majority of respondents’ facilities showed no change in rating over time. DISCUSSION Health care delivery has changed dramatically during the past 20 years and continues to evolve in a dynamic system that now includes managed care providers, large multifacility health care organizations, and increasingly diverse forms of health care delivery outside of the traditional acute care hospital. In this study, we described the status of ISCPs at a sample of United States health care facilities in the early to mid 1990s. The majority of the respondents’ health care facilities were non government owned, general acute care hospitals. Nearly 1 in 4 facilities reported that they belonged to multiple classifications (eg, both general acute care and chronic care). This observation reflects the changing health care environment in which many facilities no longer can be classified under a single type of health care delivery. Also worthy of comment is that all measures of facility size and activity except number of licensed beds declined appreciably between 1992 and 1996. In the contemporary health care environment, news of downsizing, mergers, and takeovers of health care facilities is commonplace. The impact on infection control and prevention efforts has yet to be described in detail; therefore, further evaluation is necessary. Furthermore, as reports of staffing reductions and personnel sharing increase, the question of interfacility transmission of nosocomial pathogens becomes increasingly relevant.11 Approximately 1 in 10 facilities had ISCPs supervised by more than 1 person. Several programs also existed as part of multiple departments, and ISCPs sometimes were transferred from one department to another. Only 9 (4.8%) health care facilities in this study had ISCPs that existed as freestanding departments in 1996. In the 1970s, ICPs were generally working within nursing departments (60%).17 During the current study period, the number of ISCPs located within nursing departments decreased from nearly 50% to just under 35%, whereas the number located within departments of MQR increased. This finding may signify a change in the image of infection control and its role within the health care facility with an increased emphasis on quality assurance. Further study is needed to determine whether the changes seen here have resulted in improved quality or simply consolidation of two departments and decreased personnel.

December 2000

Our study indicates that most HEs were trained specifically in infectious diseases, not infection control. This finding is consistent with a study in 1983, which showed that only 15% of hospitals had a physician with training in infection control.20 Because HEs need to participate in, supervise, and provide support for infection control activities at their health care facilities, it is essential that these professionals receive the necessary training to perform their tasks effectively. They serve as vital members of a multidisciplinary team, which includes HEs, ICPs, and other Infection Control Committee members. Therefore, emphasizing the need for multifaceted training for HEs as well as for ICPs is important. The results of this study demonstrate that most HEs were not focusing the majority of their time on infection control. A comparison between infection control–related activities (surveillance, in-service education, and other) and non–infection control–related tasks (employee health and other) revealed that the median percentage of time spent by HEs for all infection control duties combined was only 15% in 1996. Not all HEs were being remunerated for such duties, and the degree to which the remaining HEs were compensated is uncertain. Additional financial resources and support would help to underscore the need for surveillance and other infection control–related activities by an HE and serve as an indicator of their level of priority at the health care facility. In contrast to the HEs in this study, ICPs spent a greater proportion of their time on infection control activities (a median of 80% of their time in 1996). This finding differs slightly with reports from NNIS hospitals, in which ICPs spent only 68% of their time on infection control activities.7 It appears from the results of our study that ICPs today are devoting the majority of their time to infection control–related tasks, thus demonstrating the increased level of importance placed on these activities by the ICPs, their supervisors, and their facilities. With regard to ICP training and certification, results of this study were similar to those seen in the SENIC Project, in which the majority of ICPs also were registered nurses.17 Moreover, the percentage of ICPs who had attended infection control courses, whether through the Centers for Disease Control and Prevention or elsewhere, was similar in both studies (80% in the SENIC Project and 80.3% in our study).17 The overwhelming majority of respondents in this study did not report any change over time in the level of administration support for infection control. Moreover, most respondents were generally satisfied with their current level of support, with only 14.4% of facilities providing the lower ratings of 1 or 2 on a scale of 1 to 5 in 1996. Nevertheless, considering the increasing complexity of

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the in-house environment and the greater responsibility this entails, the need remains for additional administration support to intensify infection control activities, increase personnel, reduce errors, and improve quality, since infection control is one of the few areas with documented cost-benefit for health care facilities.23 At this time, the majority of nosocomial infections are reported in acute care settings.8 However, a survey of all microbiology laboratories in Ireland demonstrated that 4% of methicillin-resistant Staphylococcus aureus isolates were from community-based sources, such as nursing homes and hospices.24 Others also have noted that patients in nursing homes and other chronic care facilities are especially at risk for acquiring nosocomial infections.9 Some providers have begun to recognize the need for surveillance beyond the hospital setting, as evidenced in this study by the 44% increase in the number of facilities that perform surveillance at outpatient sites. As health care moves out of the hospital setting and into ambulatory, chronic care, and home care environments, the impact of nosocomial infections in these settings will become more apparent if systems and resources are not in place to prevent their occurrence.8 With full implementation of established infection control guidelines, it is estimated that 32% of these infections can be prevented.13 Participating hospitals in NNIS can serve as a model to prevent health care–associated infections; these facilities have achieved or surpassed year 2000 national health objectives for reductions in surgical wound infections and nosocomial infections in ICU patients.7 Approximately 13.4% of the responding health care facilities in our study were NNIS participants. Our study has several limitations. Although this is the largest report of its kind in 20 years, the sample size is small. Further, the possibility of selection bias and information bias cannot be overlooked. Deter-mining whether personnel who did not respond to this survey were fundamentally different from those in the study sample is difficult. Moreover, some data were difficult and time consuming for respondents to provide (eg, measures of facility size/activity, itemization of HE and ICP time), and it is possible that those who were able to respond to those questions differed in some way from those who left the questions unanswered. In conclusion, the impact of nosocomial infections in terms of morbidity, mortality, and financial burden cannot be overemphasized.8,10,13 Managed care and prospective payment systems make the consequences of these adverse events even more pertinent for health care facility administrators, who must grapple with shrinking health care dollars in the face of costly nosocomial infection rates.8 Professionals in infection control must be given the necessary support and resources to be effective in today’s unpredictable health care

environment. Diligent monitoring and proactive measures are necessary to ensure that ISCPs continue to be a priority, and similar studies will undoubtedly be necessary as this environment transforms. The role of infection control organizations and government agencies will remain important and collaborations will be vital as we struggle with the emerging challenges of preventing health care–associated infections in the future. References 1. Van den Broek PJ. National guideline for infection control in The Netherlands. J Hosp Infect 1999;43(Suppl):S297-9. 2. Scheel O, Stormark M. National prevalence survey on hospital infections in Norway. J Hosp Infect 1999;41:331-5. 3. Gastmeier P, Kampf G, Wischnewski N, Schumacher M, Daschner F, Ruden H. Importance of the surveillance method: national prevalence studies on nosocomial infections and the limits of comparison. Infect Control Hosp Epidemiol 1998;19:661-7. 4. Larson E. A retrospective on infection control. Part 2: twentieth century—the flame burns. AJIC Am J Infect Control 1997;25:340-9. 5. Pannuti CS, Grinbaum RS. An overview of nosocomial infection control in Brazil. Infect Control Hosp Epidemiol 1995;16:170-4. 6. Eickhoff TC. Hospital infection control: coming of age. AJIC Am J Infect Control 1993;21:115-6. 7. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety—United States, 1990-1999. MMWR Morb Mortal Wkly Rep 2000;49:149-53. 8. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol 1996;17:552-7. 9. McNeil MM, Solomon SL. The epidemiology of methicillin-resistant Staphylococcus aureus. ANNLDO (Antimicrobic Newsletter) 1985;2:49-56. 10. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol 1985;121:159-67. 11. Martone WJ. Spread of vancomycin-resistant enterococci: why did it happen in the United States? Infect Control Hosp Epidemiol 1998;19:539-45. 12. Manangan LP, Jarvis WR. Prevention of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and vancomycin-resistant enterococci (VRE) colonization/infection. Antibiot Clinicians 1998; 2 (Suppl 1):33-8. 13. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205. 14. Eickhoff TC. General comments on the study on the efficacy of nosocomial infection control (SENIC project). Am J Epidemiol 1980;111:465-9. 15. Haley RW, Quade D, Freeman HE, Bennett JV, CDC SENIC Planning Committee. Study on the efficacy of nosocomial infection control (SENIC project): summary of study design. Am J Epidemiol 1980;111:472-85. 16. Haley RW, Schachtman RH. The emergence of infection surveillance and control programs in US hospitals: an assessment, 1976. Am J Epidemiol 1980;111:574-91. 17. Emori TG, Haley RW, Stanley RC. The infection control nurse in US hospitals, 1976-1977. Am J Epidemiol 1980;111:592-607. 18. Haley RW. The “hospital epidemiologist” in United States hospi-

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tals, 1976-1977: a description of the head of the infection surveillance and control program: report from the SENIC Project. Infect Control 1980;1:21-32. 19. Emori TG, Haley RW, Garner JS. Techniques and uses of nosocomial infection surveillance in United States hospitals, 1976-1977. Am J Med 1981;70:933-40. 20. Haley RW, Morgan WM, Culver DH, White JW, Emori TG, Mosser J, et al. Update from the SENIC project—hospital infection control: recent progress and opportunities under prospective payment. AJIC Am J Infect Control 1985;13:97-108. 21. Dean AG, Dean JA, Coulombier D, Brendel KA, Smith DC, Burton AH, et al. Epi-Info version 6: a word processing, data-

base, and statistics program for epidemiology on microcomputers. Atlanta: Centers for Disease Control and Prevention; 1995. 22. SAS, Release 6.12, Software for Data Analysis. Cary, (NC): SAS Institute Inc; 1996. 23. Haley RW, White JW, Culver DH, Hughes FJ. The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system: an empirical determination from a nationally representative sample. JAMA 1987;257:1611-4. 24. Johnson Z, Fitzpatrick P, Hayes C, Sayers G, Pelly H, McDonnell B, et al. National survey of MRSA: Ireland, 1995. J Hosp Infect 1997;35:174-84.

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