Functional Aspects of the Health Care Facility Infection Control Program
Functional Aspects of the
Health Care Facility
Infection Control Program
Introduction
Health care associated infections (HAI) are a worldwide problem. They occur across
all points of health care delivery ranging from care provided in the home of the
patient to the tertiary facility that provides complex procedures such as organ
transplantation. 15 Regardless of the setting, availability of resources, country, or
populations at risk, infection control and control programs strive to achieve the
following goals in all health care facilities (HCF):

Protect the patient;

Protect health care personnel, visitors, and others in the healthcare
environment;

Accomplish the previous two goals in a cost effective manner whenever
possible. 16
Hospital-acquired infections and the importance of preventing these complications of
health care have been described in the chapter on Importance of Infection Control.
There are examples of very effective infection control programs even when
resources are limited and the epidemiologic principles upon which infection control
and control are based have universal application. 17-20
Surveillance of Hospital – Acquired infections
Surveillance is the ongoing, systematic collection, analysis, interpretation, and
dissemination of data regarding a health-related event for use in public health action
in order to reduce morbidity and mortality and to improve health. Data disseminated
by a public health surveillance system can be used for immediate public health
action, program planning, and evaluation and for formulating research hypotheses.
For example, data from a public health surveillance system can be used to:

Guide immediate action for cases of public health importance;

Measure the burden of a disease (or other health-related event), including
changes in related factors, the identification of populations at high risk, and
the identification of new or emerging health concerns;
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Functional Aspects of the Health Care Facility Infection Control Program

Monitor trends in the burden of a disease (or other health-related event),
including the detection of epidemics (outbreaks) and pandemics;

Guide the planning, implementation, and evaluation of programs to
prevent and control disease, injury, or adverse exposure;

Evaluate public policy;

Detect changes in health practices and the effects of these changes;

Prioritize the allocation of health resources;

Describe the clinical course of disease; and

Provide a basis for epidemiological research. 21
Surveillance of Hospital-acquired infections is a key function of the Infection Control
team. The same principles of surveillance used for public health can be applied to
the HCF. The major sites of Hospital-acquired infections are:

Urinary tract

Lower respiratory tract

Surgical Site

IV catheter

Skin and soft tissue
The relative distribution of these is illustrated graphically (Figure 5) using data
derived from a prevalence survey of infections in France. 22 The steps involved in
surveillance are outlined in the flow diagram (Figure 6). The collection, analysis, and
dissemination of surveillance data have been shown to be the single most important
factor in prevention of Hospital-acquired infections.
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Functional Aspects of the Health Care Facility Infection Control Program
Fig. 5: Sites of the most common nosocomial infections
(Distribution according to the French national prevalence survey (1996)*)
Adapted from (Enquete nationale de prevalence des infections nosocomiales, 1996, BEH, 1997, 36: 161-163)
Fig. 6: Simplified example of steps in a surveillance system
Occurrence of health-related event
Health-related event recognized by
reporting source
Health-related event reported to
responsible public health agency
Feedback to stakeholders
Control and prevention activities
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Functional Aspects of the Health Care Facility Infection Control Program
Some of the critical elements of a surveillance program for Hospital-acquired
infections include standardized definitions and a clear purpose. The program
needs to balance the resources available, the priorities for data collection (e.g.,
ongoing evidence of infusion-associated bloodstream infection), the population
served by the facility, and the facility’s objectives. Standardized definitions have
been developed. 23-24 If a facility has limited laboratory or other diagnostic
facilities, more simplified definitions such as those in the table below might be
helpful. When diagnostic capabilities are constrained, there have been
successful examples of international collaboration using cohorts of patients with
simple symptom-driven criteria for finite time periods. 25 However, if external,
standardized definitions are not available, then written ones can be developed.
These should emphasize intra-facility standardization. 22
Table 3: Simplified criteria for surveillance of nosocomial infections
Type of nosocomial infection
Simplified criteria
Surgical site infection
Any purulent discharge, abscess, or
spreading cellulites at the surgical site
during the month after the operation
Urinary infection
Positive urine culture (1 or 2 species ) with
at least 10 bacteria/ml with or without
clinical symptoms
Respiratory symptoms with at least 2 of
the following signs appearing during
hospitalization
Respiratory infection
Cough
Purulent sputum
New infiltrate on chest radiograph
consistent with infection
Vascular catheter infection
Inflammation, lymphangitis, or purulent
discharge at the site of catheter
Septicemia
Fever or rigors with at least one positive
blood culture
One step that often is incomplete or missed in a surveillance program is
dissemination of findings from the program to those who need to know, e.g.,
direct care personnel. A description of one such program that has been
successful is the National Nosocomial Infections Surveillance (NNIS) system. 26
Recommended practices for surveillance have been described. 27
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Functional Aspects of the Health Care Facility Infection Control Program
The steps outlined in these practices are:

Assess the population served by the facility so that interventions can
be directed at those complications of greatest importance given
available resources.

Select the outcome (surgical site infection) or process (frequency that
the personnel disinfect tops of stoppers in multiuse medication vials)
for surveillance.

Define all data elements and assure criteria definitions are valid,
accurate, and reproducible.

Collect the surveillance data.

Calculate and analyze surveillance rates.

Apply risk stratification methodology.

Report and distribute surveillance information.
Table 4: Prevalence and incidence rates
Prevalence rate
Examples
Prevalence (%) of nosocomial
infections (NI) for 100 hospitalized
Number of infected patients* at the time
of study / Number of patients observed at patients
the same time x 100
Prevalence (%) of urinary tract
(*or number of infections)
infections (UTI) for 100 hospitalized
patients
Number of infected patients at the time of
Prevalence (%) of UTI for 100 patients
study / Number of patients exposed at
with a urinary catheter
the same time x 100
Attack rate (cumulative incidence
Examples
rate)
Number of new infections acquired in a
Attack rate (%) of UTI for 100
period / Number of patients observed in
hospitalized patients
the same period x 100
Number of new infections acquired in a
Attack rate (%) of surgical site
period / Number of patients exposed in
infections (SSI) for 100 hospitalized
the same period x 100
patients who went through surgery
Incidence rate
Examples
Number of new nosocomial infections
acquired in a period /
Incidence of bloodstream infection
Total of patient-days for the same period (BSI) for 1000 patient-days
x 1000
Number of new device-associated
nosocomial infections in a period /
Incidence of ventilator-associated
Total device-days for the same period
pneumonia for 1000 ventilation-days
x 1000
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Functional Aspects of the Health Care Facility Infection Control Program
In general, collection of numerators and denominators for the surveillance
program is one that requires active methods. Passive surveillance, which relies
on reports from others, has low sensitivity. Additional examples of surveillance
methods and tools are available and should be reviewed for additional details. 22
Investigation and Control of Outbreaks
Outbreaks or clusters of Hospital-acquired infections are usually rare. These
consume <5% of the Infection Control team’s time and have an estimated
frequency of 1/10,000 admissions. However when they occur, prompt
investigation and control is important to prevent additional cases and to assure a
return to safe care of patients. 28
Components of an outbreak investigation are:

Confirmation that an outbreak or cluster exists (are the numbers
unusual or more than expected?).

Establishment or verification of diagnosis of observed cases;
assurance of proper identification of the pathogen involved.

Search for additional cases; collection of critical data and specimens
(important: save isolates from the patients for molecular typing).

Characterization of cases by time, place, person, procedures,
equipment used, etc.

Formulation of a tentative hypothesis on potential reservoir and mode
of transmission.

Institution of control measures as indicated and appropriation and then
evaluation of the efficacy of these.

Communication of findings; write final report.
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