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Surveillance: Retrospective versus prospective
Surveillance: Retrospective versus prospective Sandra Blake, R.N., B.S.N., Esther Cheatle, M.D., Betty Mack, R.N., Springfield. III
A survey was undertaken to determine if a retrospective review of charts for nosocomial infections could be as accurate as a prospective review of charts. The retrospective review was done by medical record technicians using criteria established by the Infection Control Committee and the medical staff. The infection control nurse reviewed the data collected by the Medical Records Department before the monthly report was completed. Surveillance was done prospectively by the infection control nurse and an R.N. helper. The study was carried out on two nursing units. The infection control team used the same criteria as the medical record technicians. At the end of the 4-month study period, infections found by medical record technicians were compared to those found by the infection control team. The Medical Records Department identified more nosocomial infections than did the nurse team. It was concluded that the Medical Records Department can do an accurate review of charts for nosocomial infection and that their report is reliable to show basic trends. The infection control nurse is then able to spend her time on special studies and investigations as well as employee education. (A.\1 J INfECT CONTROL 8:75, 1980.)
Surveillance for nosocomial infections is recognized as an essential component of an effective infection control program. Surveillance may be defined as a system for collecting, tabulating, analyzing, and reporting data on the occurrence of nosocomial infections.' Many survcillancc methods have been described by various experts, but all effective systems have one common requirement, available time in which to collect the data. A good surveillance program provides the following information": 1. Identification of nosocomial pathogens commonly encountered in the particular environment 2. Estimates of endemic levels of nosocomial infection for a particular hospital and for the individual services Reprint requests: Sandra Blake. R.N.. B.S.N, Infection Control Nurse, Memorial Medical Center. 800 N. Rutledge. Springfield. IL 62702. 0196-6553/80:030075+04$004010
© 1980 Assoc Pract. Infect Control
3. Prompt recognition of epidemics 4. Identification of educational needs of hospital personnel regarding good infection control practices A method for surveillance of nosocomial infections has been described by the Center for Disease Control and is also supported by the American Hospital Association. This approach utilizes a surveillance person who makes rounds on the nursing units (preferably daily) to review charts of patients in isolation or rcceiving antibiotics and special treatments and whoalso visits the X-Ray Department to review positive chest findings.":" The Center for Disease Control advocates that a full-time surveillance person be employed in hospitals that have more than 400 beds based on a ratio of 10 hours per week per 100 beds. A somewhat modified approach has been described by other authors. One method described utilizes a weekly review of the nursing care plan to select high-risk patients for a chart 75
Amencan Journal of
76 Blake, Cheatle, and Mack
review. However, in this study about 65% of the total population fell into the high-risk group; therefore large numbers of charts still require review by the surveillance person." In our teaching hospital, obtaining the patient's chart for review is often a problem as the chart is frequently being used by the medical staff or may be off the unit with the patient in another department such as radiology or physical therapy. Nursing personnel are also very busy, and it is often difficult to discuss a patient's condition with the nurse in charge of his care. These problems all increase the amount of time required for surveillance. Our Infection Control Committee believed that employee education should have at least as much emphasis as surveillance. Therefore total hospital surveillance seemed impossible. Possible solutions to this dilemma were to hire more surveillance personnel or do smaller studies concerning individual problems such as wound infections during a designated period of time. Employing additional personnel was not possible. It was decided to abandon total surveillance and concentrate on selected studies and employee education. However, in reviewing our problem it was found that medical records administrators were already accumulating data on hospital infections. These personnel were trained to use the definitions of infection approved by the Infection Control Committee and medical staff in reviewing charts. Data were collected retrospectively. However, the Infection Control Committee was unsure if data collected and reported by the Medical Records Department was as accurate as data collected prospectively by the infection control nurse. In fact, some authors have stated that review of nosocomial infections by the medical records technicians would be an inaccurate means of surveillance." Therefore a special surveillance study on two nursing units was conducted to compare surveillance data collected retrospectively by the Medical Records Department and prospectively by the infection control personnel. It was hypothesized that the prospective data collected by the nurses would be more accurate. The study was done over a 4-month period.
INFECTION CONTROL
METHODS The same guidelines for identification and classification of infections were used by both medical record technicians and infection control personnel. These guidelines were adaptations of those recommended by the CDC. All charts were reviewed by the Medical Records Department within several days of discharge. The same two individuals in this department reviewed the charts, searching for documentation of nosocomial infections. Information recorded included the patient's name, record number, service, nursing unit, site of infection, criteria present on the chart, cultures and other significant laboratory reports, treatment, admission dates, and discharge dates. These data were then reviewed by the infection control nurse. Finally, the data were assimilated into the report that comprises the monthly nosocomial infection report and was always completed within 4 weeks after the end of a month. Once a month the infection control nurse spent about 6 hours reviewing data collected by the Medical Records Department. Prospective surveillance was done on the two nursing units (a medical unit and a surgical unit) by two nurses. The two nursing units were visited two to three times per week. Patient charts were reviewed with module leaders using the Kardex care plan as a basis for discussion. Special attention was given to patients with elevated temperatures, those on antibiotic therapy or special treatments such as soaks and irrigations, patients with intravenous catheters or Foley catheters, and patients in isolation. Also charts of patients with positive microbiology cultures were reviewed. When an infection was identified, data were collected on a special surveillance sheet. Data collected included the patient's name, physician's diagnosis, nursing unit, site of infection, organisms isolated and their sensitivities, surgical procedures, and predisposing factors. Monthly reports were prepared for each of the two units. Prior to commencing this surveillance, in-service conferences were conducted to acquaint unit nurses with the study objectives and the guidelines used in determining the presence of an infection.
Volume 8 Number 3 August. 1980
RESULTS
At the en d of the study, cases of infections foun d by the Med ical Records Departm en t were compare d to those foun d by the nur se team in t hes e t wo un its . Th e d at a we re r eviewed by a sta tistician to esta b lis h whet her th ere was a difference in efficacy (in re porti ng rates) for the two a pproaches a n d to es ta b lis h th e extent of such a d ifference if one exi sted. Th e data collected a re sho w n in Table 1. To determine if there was a difference in reporting for the tw o a p proache s, a McNema r test of correlated p roportions with a significa nce level of 0.05 w as used . Th e value obtaine d fro m the McNema r test was 5.26 , or using t he Yates "correction for co n t inui ty," a va lue of 4 .35. This sta tistic is co m pa re d to the 0 .05 critical va lue of th e ch i-sq uare di st ributio n , wh ich is 3.84. S in ce the va lue obtained exceeds the cr itical va lue , a hyp othesis of no di fference is rej ect ed. Th e Medical Records Depa rtmen t, in fact , reported more infections tha n the nurse team. Statis tical m ethods to assess the ex te nt of the differ ence we re a lso used . It was determined that of the infec tions reported by the medical record technici ans , 35% were mi ssed by the nurse team. Of those re po rted by the nurses , 16% were missed by the m edical record techn ici ans. CONCLUSION
In su m m ar y , the rep o rt ed infection rate s of the t wo methods wer e fou nd to be different. Th e Medical R ecords Depart m ent mi ssed s u bstan tially fewer of t he in fect ions reported by the nurse team than t he nurse tea m mi ssed of those re por ted by the Medical Record s Depa rtment . Therefore it was co ncl uded th at the Med ical Records Dep a r tm en t was more sensitive to ide n tifying infections than the nurse team. In evaluating th e resu lts of this surv ey, there are several po ints of di scussion. First , why we re the medical records personnel more se ns it ive to identifyin g in fection s than the nurse tea m ? Sever al obvious rea sons exist that may ex p lain this di fference. First , a ll reco r ds a re re vie wed by the sa m e personn el in the Medical Records
Surveillance: R etrospect ive vs . prospective
77
Table 1. Nosocomial infections found by the Medic al Records Depa rtment and /o r the infect ion control team
Patients discharged Noninfected Detected by nurses only Detected by Med ical Record s Dept. only Detected by both Disrepancy between report s
Ward A
Ward B
Total
685 651 4 7
492 470 2 10
1177 1121 6
21 2
10
31 2
0
17
Dep a rtment. These people are consistent in th ei r use of the criteria for id entifying infectio ns . On the ot her ha nd , t he two nu rses were occasio nally absent at the sa me ti m e an d th erefo re di d no t review all patient charts during the course of the survey. It was no ted that some of the infections mi ssed by t he nu rse tea m did occur during the ir absence . In ad diti on, a t least one infec tion was missed b y the nurse team becaus e the pat ient di ed be tween the nurse's vis it to the un it a n d the incident was no t broug ht to the a tte ntion of t he nurse tea m. Ho we ve r , la borat ory data pl u s the physician 's co mments were on the patient 's record, thus a llowing the Medical Records Dep a rt ment to id e ntify this infection. The nurse te a m di d review the infec tions found by the Medical Record s Department and found they counted two infections that the nurse team would no t ha ve coun te d . However, bo th of these infection s had been diagnosed by a physici an. In th is stu dy the Medical Recor ds Dep a r tm ent di d prove to be efficient and accurate in identifying nosoco mial infections . In o ur 600- bed hospital this system can en hance the a bi lit y of infection co nt ro l per so nnel to expand su rvei llance activ it ies . Because the Med ical Recor ds Dep artment can supply th e infectio n co ntrol team wit h monthl y da ta on th e occurrence of nosocomia l infect ions , both for the entire h ospital and for the individua l un its a n d services , a nd sites of infect ion and organisms isol a ted , the infectio n control team 's surveillance activities can be d irected to wa rd mo re specific studies. Th e Medical R ecor ds Dep artment report can provide ba seline data every m o n t h
American Journal of
78 Blake, Ch eatle, and Mack
INFECTION CON TROL
tha t shou ld indicate trends . When an increase in infections or a potential problem is identifi ed , a specia l study can be conducted . For exa m p le , if an increase in the wound infection rate of clean surgical cases is noted, an in-depth st udy can be done by the infection control team. In conclusion, by having the Medical Records Department compile a monthly nosocomial r eport, the infection control team is provided the ba sic data ne e ded , leaving more time ava ila ble for special studies and employee ed u cation. ADDENDUM Sinc e completion of th is study . efforts ha ve been m ad e to ex pa nd the useful ness of thi s retrospecti ve su rve il la nce system . At th e present time the us e of a ca r bo ne d wor ks heet is bein g eva lua te d. As soon as the medical record s techni cians review the ch arts a nd com plete the wo rk sh eet . a cop y of the sheet is sen t to the infection con trol nurse . Also . rather than doing a review of th e charts a t th e e nd of the month . th e infection control nurse is pl anning to review th e infec tions identified b y th e Medical Records Dep a rtment on a weekl y ba sis . In addition. " b ug surveillance ." a s described by Maryanne McGuckin, infection co n tro l practitioner a t th e Hospital of th e Uni versit y of Pennsylvania. is being initiated . This " b ug surve ill a nce" has be en
d esigned to detect potenti al ep ide m ics with the u se of mi crobiology r eports fr om th e laboratory. Thi s method p rovides d at a d ail y .' Microbiology reports a re b eing recorded d ail y by a cleri cal as sis ta n t. It is bel ieved that th ese sy ste m s to gether will prov ide a thorough but tim esav in g sys te m for no socomi al infection surveillance. We wish to th ank Tom Men ten for his assi st an ce in th e s ta tist ica l evaluation of th e d at a .
References I . Krause S. Pappas S: The nurse epidem iologist : Role and res p onsibili ties . Top Clin Nurs 1:2-3 , July, 1979 2. Ei ckhoff T, Branch ma n P. Bennett J , et al: Surveillance of nosocomial infection in co m mun ity hospitals. 1. Surveillance methods, effectiven ess . a nd initial results . J Infect Dis 120:305 -317, 1969 3. Amer ican Hospital Associ at ion : Infection control in th e hospital. Chicago. 1979 . Th e Association , pp 24-25 4. Garner JS . Bennett JB. Sch eckl er WE . et al : Surveillan ce of nosocomi al in fecti on s . I n Pro ceedings of th e Intern at ion al Conferen ce on Nosocomial Infections . Atlanta . Aug 1970, Center for Disea se Control, pp 277-281 5. Wenzel R . Osterman D, Hunting K, et a l: Hospital ac q uire d infections. Surveilla nce in a univer sity ho spital . Am J Epidemiol 103:251 . 1976 6. Macpher son CR . Practical problem s in the detecti on of hospital-acquired infections . Am J Clin Pathol 50 :155 . 1967 7 . McGu ckin M: An innovative a ppro ac h to surv eilla nc e of no comial outbreak s. Qu al Rev Bull, March . pp 12-17 . 1979
Classified advertising The American Journal of intection Control offe rs a classi fied advertising section in each issue. It lists positi ons available and positions desired . Rates for announcements of 30 word s 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 c harge for box servic e for the first insertion only. Payment must acco mpany insertion orders. Send classified ads to the Journal Adve rtising Department , American Journ al of Infect ion Control, The C V Mosby Comp any, 11830 Westline Indu strial Drive, SI Louis, MO 63141 .
A survey was undertaken to determine if a retrospective review of charts for nosocomial infections could be as accurate as a prospective review of charts. The retrospective review was done by medical record technicians using criteria established by the Infection Control Committee and the medical staff. The infection control nurse reviewed the data collected by the Medical Records Department before the monthly report was completed. Surveillance was done prospectively by the infection control nurse and an R.N. helper. The study was carried out on two nursing units. The infection control team used the same criteria as the medical record technicians. At the end of the 4-month study period, infections found by medical record technicians were compared to those found by the infection control team. The Medical Records Department identified more nosocomial infections than did the nurse team. It was concluded that the Medical Records Department can do an accurate review of charts for nosocomial infection and that their report is reliable to show basic trends. The infection control nurse is then able to spend her time on special studies and investigations as well as employee education. (A.\1 J INfECT CONTROL 8:75, 1980.)
Surveillance for nosocomial infections is recognized as an essential component of an effective infection control program. Surveillance may be defined as a system for collecting, tabulating, analyzing, and reporting data on the occurrence of nosocomial infections.' Many survcillancc methods have been described by various experts, but all effective systems have one common requirement, available time in which to collect the data. A good surveillance program provides the following information": 1. Identification of nosocomial pathogens commonly encountered in the particular environment 2. Estimates of endemic levels of nosocomial infection for a particular hospital and for the individual services Reprint requests: Sandra Blake. R.N.. B.S.N, Infection Control Nurse, Memorial Medical Center. 800 N. Rutledge. Springfield. IL 62702. 0196-6553/80:030075+04$004010
© 1980 Assoc Pract. Infect Control
3. Prompt recognition of epidemics 4. Identification of educational needs of hospital personnel regarding good infection control practices A method for surveillance of nosocomial infections has been described by the Center for Disease Control and is also supported by the American Hospital Association. This approach utilizes a surveillance person who makes rounds on the nursing units (preferably daily) to review charts of patients in isolation or rcceiving antibiotics and special treatments and whoalso visits the X-Ray Department to review positive chest findings.":" The Center for Disease Control advocates that a full-time surveillance person be employed in hospitals that have more than 400 beds based on a ratio of 10 hours per week per 100 beds. A somewhat modified approach has been described by other authors. One method described utilizes a weekly review of the nursing care plan to select high-risk patients for a chart 75
Amencan Journal of
76 Blake, Cheatle, and Mack
review. However, in this study about 65% of the total population fell into the high-risk group; therefore large numbers of charts still require review by the surveillance person." In our teaching hospital, obtaining the patient's chart for review is often a problem as the chart is frequently being used by the medical staff or may be off the unit with the patient in another department such as radiology or physical therapy. Nursing personnel are also very busy, and it is often difficult to discuss a patient's condition with the nurse in charge of his care. These problems all increase the amount of time required for surveillance. Our Infection Control Committee believed that employee education should have at least as much emphasis as surveillance. Therefore total hospital surveillance seemed impossible. Possible solutions to this dilemma were to hire more surveillance personnel or do smaller studies concerning individual problems such as wound infections during a designated period of time. Employing additional personnel was not possible. It was decided to abandon total surveillance and concentrate on selected studies and employee education. However, in reviewing our problem it was found that medical records administrators were already accumulating data on hospital infections. These personnel were trained to use the definitions of infection approved by the Infection Control Committee and medical staff in reviewing charts. Data were collected retrospectively. However, the Infection Control Committee was unsure if data collected and reported by the Medical Records Department was as accurate as data collected prospectively by the infection control nurse. In fact, some authors have stated that review of nosocomial infections by the medical records technicians would be an inaccurate means of surveillance." Therefore a special surveillance study on two nursing units was conducted to compare surveillance data collected retrospectively by the Medical Records Department and prospectively by the infection control personnel. It was hypothesized that the prospective data collected by the nurses would be more accurate. The study was done over a 4-month period.
INFECTION CONTROL
METHODS The same guidelines for identification and classification of infections were used by both medical record technicians and infection control personnel. These guidelines were adaptations of those recommended by the CDC. All charts were reviewed by the Medical Records Department within several days of discharge. The same two individuals in this department reviewed the charts, searching for documentation of nosocomial infections. Information recorded included the patient's name, record number, service, nursing unit, site of infection, criteria present on the chart, cultures and other significant laboratory reports, treatment, admission dates, and discharge dates. These data were then reviewed by the infection control nurse. Finally, the data were assimilated into the report that comprises the monthly nosocomial infection report and was always completed within 4 weeks after the end of a month. Once a month the infection control nurse spent about 6 hours reviewing data collected by the Medical Records Department. Prospective surveillance was done on the two nursing units (a medical unit and a surgical unit) by two nurses. The two nursing units were visited two to three times per week. Patient charts were reviewed with module leaders using the Kardex care plan as a basis for discussion. Special attention was given to patients with elevated temperatures, those on antibiotic therapy or special treatments such as soaks and irrigations, patients with intravenous catheters or Foley catheters, and patients in isolation. Also charts of patients with positive microbiology cultures were reviewed. When an infection was identified, data were collected on a special surveillance sheet. Data collected included the patient's name, physician's diagnosis, nursing unit, site of infection, organisms isolated and their sensitivities, surgical procedures, and predisposing factors. Monthly reports were prepared for each of the two units. Prior to commencing this surveillance, in-service conferences were conducted to acquaint unit nurses with the study objectives and the guidelines used in determining the presence of an infection.
Volume 8 Number 3 August. 1980
RESULTS
At the en d of the study, cases of infections foun d by the Med ical Records Departm en t were compare d to those foun d by the nur se team in t hes e t wo un its . Th e d at a we re r eviewed by a sta tistician to esta b lis h whet her th ere was a difference in efficacy (in re porti ng rates) for the two a pproaches a n d to es ta b lis h th e extent of such a d ifference if one exi sted. Th e data collected a re sho w n in Table 1. To determine if there was a difference in reporting for the tw o a p proache s, a McNema r test of correlated p roportions with a significa nce level of 0.05 w as used . Th e value obtaine d fro m the McNema r test was 5.26 , or using t he Yates "correction for co n t inui ty," a va lue of 4 .35. This sta tistic is co m pa re d to the 0 .05 critical va lue of th e ch i-sq uare di st ributio n , wh ich is 3.84. S in ce the va lue obtained exceeds the cr itical va lue , a hyp othesis of no di fference is rej ect ed. Th e Medical Records Depa rtmen t, in fact , reported more infections tha n the nurse team. Statis tical m ethods to assess the ex te nt of the differ ence we re a lso used . It was determined that of the infec tions reported by the medical record technici ans , 35% were mi ssed by the nurse team. Of those re po rted by the nurses , 16% were missed by the m edical record techn ici ans. CONCLUSION
In su m m ar y , the rep o rt ed infection rate s of the t wo methods wer e fou nd to be different. Th e Medical R ecords Depart m ent mi ssed s u bstan tially fewer of t he in fect ions reported by the nurse team than t he nurse tea m mi ssed of those re por ted by the Medical Record s Depa rtment . Therefore it was co ncl uded th at the Med ical Records Dep a r tm en t was more sensitive to ide n tifying infections than the nurse team. In evaluating th e resu lts of this surv ey, there are several po ints of di scussion. First , why we re the medical records personnel more se ns it ive to identifyin g in fection s than the nurse tea m ? Sever al obvious rea sons exist that may ex p lain this di fference. First , a ll reco r ds a re re vie wed by the sa m e personn el in the Medical Records
Surveillance: R etrospect ive vs . prospective
77
Table 1. Nosocomial infections found by the Medic al Records Depa rtment and /o r the infect ion control team
Patients discharged Noninfected Detected by nurses only Detected by Med ical Record s Dept. only Detected by both Disrepancy between report s
Ward A
Ward B
Total
685 651 4 7
492 470 2 10
1177 1121 6
21 2
10
31 2
0
17
Dep a rtment. These people are consistent in th ei r use of the criteria for id entifying infectio ns . On the ot her ha nd , t he two nu rses were occasio nally absent at the sa me ti m e an d th erefo re di d no t review all patient charts during the course of the survey. It was no ted that some of the infections mi ssed by t he nu rse tea m did occur during the ir absence . In ad diti on, a t least one infec tion was missed b y the nurse team becaus e the pat ient di ed be tween the nurse's vis it to the un it a n d the incident was no t broug ht to the a tte ntion of t he nurse tea m. Ho we ve r , la borat ory data pl u s the physician 's co mments were on the patient 's record, thus a llowing the Medical Records Dep a rt ment to id e ntify this infection. The nurse te a m di d review the infec tions found by the Medical Record s Department and found they counted two infections that the nurse team would no t ha ve coun te d . However, bo th of these infection s had been diagnosed by a physici an. In th is stu dy the Medical Recor ds Dep a r tm ent di d prove to be efficient and accurate in identifying nosoco mial infections . In o ur 600- bed hospital this system can en hance the a bi lit y of infection co nt ro l per so nnel to expand su rvei llance activ it ies . Because the Med ical Recor ds Dep artment can supply th e infectio n co ntrol team wit h monthl y da ta on th e occurrence of nosocomia l infect ions , both for the entire h ospital and for the individua l un its a n d services , a nd sites of infect ion and organisms isol a ted , the infectio n control team 's surveillance activities can be d irected to wa rd mo re specific studies. Th e Medical R ecor ds Dep artment report can provide ba seline data every m o n t h
American Journal of
78 Blake, Ch eatle, and Mack
INFECTION CON TROL
tha t shou ld indicate trends . When an increase in infections or a potential problem is identifi ed , a specia l study can be conducted . For exa m p le , if an increase in the wound infection rate of clean surgical cases is noted, an in-depth st udy can be done by the infection control team. In conclusion, by having the Medical Records Department compile a monthly nosocomial r eport, the infection control team is provided the ba sic data ne e ded , leaving more time ava ila ble for special studies and employee ed u cation. ADDENDUM Sinc e completion of th is study . efforts ha ve been m ad e to ex pa nd the useful ness of thi s retrospecti ve su rve il la nce system . At th e present time the us e of a ca r bo ne d wor ks heet is bein g eva lua te d. As soon as the medical record s techni cians review the ch arts a nd com plete the wo rk sh eet . a cop y of the sheet is sen t to the infection con trol nurse . Also . rather than doing a review of th e charts a t th e e nd of the month . th e infection control nurse is pl anning to review th e infec tions identified b y th e Medical Records Dep a rtment on a weekl y ba sis . In addition. " b ug surveillance ." a s described by Maryanne McGuckin, infection co n tro l practitioner a t th e Hospital of th e Uni versit y of Pennsylvania. is being initiated . This " b ug surve ill a nce" has be en
d esigned to detect potenti al ep ide m ics with the u se of mi crobiology r eports fr om th e laboratory. Thi s method p rovides d at a d ail y .' Microbiology reports a re b eing recorded d ail y by a cleri cal as sis ta n t. It is bel ieved that th ese sy ste m s to gether will prov ide a thorough but tim esav in g sys te m for no socomi al infection surveillance. We wish to th ank Tom Men ten for his assi st an ce in th e s ta tist ica l evaluation of th e d at a .
References I . Krause S. Pappas S: The nurse epidem iologist : Role and res p onsibili ties . Top Clin Nurs 1:2-3 , July, 1979 2. Ei ckhoff T, Branch ma n P. Bennett J , et al: Surveillance of nosocomial infection in co m mun ity hospitals. 1. Surveillance methods, effectiven ess . a nd initial results . J Infect Dis 120:305 -317, 1969 3. Amer ican Hospital Associ at ion : Infection control in th e hospital. Chicago. 1979 . Th e Association , pp 24-25 4. Garner JS . Bennett JB. Sch eckl er WE . et al : Surveillan ce of nosocomi al in fecti on s . I n Pro ceedings of th e Intern at ion al Conferen ce on Nosocomial Infections . Atlanta . Aug 1970, Center for Disea se Control, pp 277-281 5. Wenzel R . Osterman D, Hunting K, et a l: Hospital ac q uire d infections. Surveilla nce in a univer sity ho spital . Am J Epidemiol 103:251 . 1976 6. Macpher son CR . Practical problem s in the detecti on of hospital-acquired infections . Am J Clin Pathol 50 :155 . 1967 7 . McGu ckin M: An innovative a ppro ac h to surv eilla nc e of no comial outbreak s. Qu al Rev Bull, March . pp 12-17 . 1979
Classified advertising The American Journal of intection Control offe rs a classi fied advertising section in each issue. It lists positi ons available and positions desired . Rates for announcements of 30 word s 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 c harge for box servic e for the first insertion only. Payment must acco mpany insertion orders. Send classified ads to the Journal Adve rtising Department , American Journ al of Infect ion Control, The C V Mosby Comp any, 11830 Westline Indu strial Drive, SI Louis, MO 63141 .