PRACTICE FORUM

Rebecca Wurh, MD
Margaret Dolan, MD
Barbara O’Neal, RN
Elvira Azarcon, RN
Chicago, Illinois

Cook County Hospital is a large, municipal teaching hospital with multiple academic
affiliations. We sought to provide uniform infection control orientation and screening for
students because many had no previous training in body substance isolation systems or
infection control and trainees may be more likely to be exposed to hospital-acquired
infections because of their inexperience. Each student or visiting resident must complete
an educational program once each year. The program consists of a pretest, a video, and
group discussion, with examples of needle-disposal boxes and protective gear,
information about ways to avoid needlesticks and mucosal splashes, what to do if a
contact occurs, and information on isolation and tuberculosis. The session ends with a
posttest, which is then retained on file. All trainees are also required to provide a
“certificate of compliance” with the hospital’s infectious disease serology screening
program, which includes measles, rubella, and hepatitis B surface antigen testing, as well
as tuberculin skin testing. Trainees must provide an updated form annually. The program
is costly, both in dollars and in personnel time, for visiting students and the hospital.
Tuberculin skin test screening detected a cluster of purified protein derivative skin test
conversions in medical students. (AJIC AM J INFECT CONTROL 1994;22:322-4)

Cook County Hospital (CCH) is a large, urban, of their relative inexperience in procedures and
teaching hospital with multiple academic affilia- specimen handling and because of their intense
tions. Approximately 150 medical, nursing, podia- clinical exposure.’
try, dental, radiology, and lab technician students At the time of the implementation of the
and residents from local, out-of-state, and foreign BSIS program, inquiries to local schools re-
educational programs, perform clinical rotations vealed that few students received any instruction
each month. on infection control or BSIS. At the same time,
When the hospital implemented a body sub- a nationwide measles outbreak forced us to re-
stance isolation system (BSIS) in 1989, all hos- view our mandated employee infectious dis-
pital employees were oriented to the new pro- ease serologic screening program. We used
gram and continue to be updated annually. the opportunity to consider the role of infec-
House staff in the hospital-based training pro- tious disease education and screening for visit-
grams also receive annual training in infection ing students and residents, and we devel-
control. However, students-who did not receive oped a program to provide BSIS training and
training-may be more likely to be exposed to infectious disease screening for all visiting stu-
blood and body substances than other hospital dents.
personnel during their clinical rotations because
IMPLEMENTATION
From the Divisions of Hospital Epidemiology and Planning, In 1989, CCH reviewed the need for infection
Education, and Research, Cook County Hospital, Chicago, Illinois. control education and screening requirements
Reprint requests: Rebecca Wurtz, MD, CCSN 1028, Cook County with the academic deans at all schools with
Hospital, 1835 W. Harrison, Chicago, IL 60612. educational agreements with the hospital, to seek
Copyright 0 1994 by the Association for Professionals in Infection the schools’ cooperation. All schools were ame-
Control and Epidemiology, Inc. nable to the program. Starting in mid-1989, all
0196-6553194 $3.00 + 0 17149151621 students were notified of the requirement when

322
 Wurtz et al. 323

they signed up for a rotation at CCH and were Table 1. Requirements for certificate
instructed to present themselves for orientation of compliance
programs before proceeding to the departmental
Tuberculosis screening
office for assignment. Annual PPD (with date and result)
If PPD previously positive, results of CXR done wlthln 4
PROQRAM years
Each visiting student and visiting resident must Documented rubella Immunity
Rubeola
complete an educational program once a year.
Born before January 1, 1957
Infection control programs take precedence over Documented rubeola immunity
departmental orientation. Programs are offered Hepatitis 6
two times a week, scheduled to coincide with the If previously vaccinated, hepatitis B surface antibody
beginning of various clinical rotations. The edu- If never vaccinated, hepatitis B surface antigen testing
cational program is an hour-long combination of
Form must be signed by health care worker who performed and Interpreted
pretest, video, group discussion, and posttest. tests and must be imprinted with official stamp or seal of student’s institution
The pretest asks 12 questions, focusing on such PPD. Purified protein derivative of tuberculin. CXR, chest x-ray

common clinical practices as needle disposal,

personal protective gear, and isolation room re-
quirements. The video, which runs 20 minutes, is
a commercially available video (HospitaZ In@-
tions, produced by Parker Productions, San Ma-
teo, Calif.) aimed at all types of clinical health care
workers (nurses, laboratory technicians, environ-
mental services workers), followed by a 15minute
video produced by our hospital on the special
provisions of the hospital’s BSIS program.
Group discussion follows the video, with ex-
amples of needle-disposal boxes and protective
gear, where to find them, and when to use them.
There is further verbal instruction about ways to
avoid needlesticks and mucosal splashes, and
what to do if such a contact occurs. The session
ends with a posttest, which repeats the same
questions asked in the pretest. Both are then
reviewed by the group with the instructor. The
completed tests are retained on file.
Since early 1992, instruction has included
information on isolation and tuberculosis, includ-
ing the meaning and implementation of tubercu-
losis isolation and the use of protective gear, such
as particulattl respirators.
Sxeening
All student.+ and visiting residents are required
to provide a “certificate of compliance” with the
hospital’s ind‘ectious disease serology screening
program, the same serologic screening and puri-
fied protein derivative of tuberculin (PPD) skin
testing that new employees undergo. Require-
ments for compliance are summarized in the
table. The form must be signed by the trainee,
giving permission to release the information to
CCH, and must be signed by the student’s health
care provider. The form is kept on file and is valid
for 1 year. Third- and fourth-year medical and
nursing students provide a form at the beginning
of the academic year. Students who visit CCH for
a single month or part of a year must provide the
form at the beginning of their first rotation.
Obtaining compliance
Students cannot start clinical duties without a
hospital identification card. To receive a hospital
identification card, each student must complete
the BSIS orientation program and provide or have
on file a copy of serologic screening results.
Identification cards are good only for the length of
the current rotation, with expiration dates promi-
nently displayed, thereby ensuring that students
will get an updated identification card for each
rotation. The department chairperson is notified if
a student assigned to clinical duties has not
completed the orientation program, and the chair-
person is responsible for seeing that the student
attends the next program.
When the program was implemented, there
were some objections by students. During the last
year, however, it has been accepted without
resistance. Academic deans at associated training
programs have endorsed the program.
Cost and personnel requirements
Costs of the program include hospital personnel
salaries and the cost to students for the screening
tests and medical visit. CCH has provided one
full-time administrator, with full-time secretarial
support, to coordinate student enrollment, review
certificates of compliance, and conduct the train-
ing session. The entire hospital process - partici-
pating in the training program, checking forms,
and issuing identification cards -takes 3 to 4
hours on the first day of the rotation.
 AJIC
224 Wurtz et al. October 1994

Students must make an annual visit to a physi- borne pathogens exposure but does not provide it
cian or medical office for testing and certification. to visiting students. Although we encourage
All of the participating medical student and schools to provide this vaccination to students, we
medical resident programs have student health do not require it of our participating institutions.
services that provide serologic and PPD testing This is another area in which hospitals and
free, but few nursing and medical technician educational programs should work together.
programs have such routine medical back-up. Although the hospital is not liable for workman’s
Some students are forced to rely on private compensation for nonemployee clinical visitors, it
physicians and pay some of the costs out of pocket. has made the commitment to provide appropriate
immediate and follow-up evaluation, prophylaxis,
DISCUSSION screening, and counseling for students who have
Our municipal hospital has many academic had parenteral or mucosal exposure to blood or
affiliations. Students from many types of training body substances during their clinical rotations.
programs, and with many different backgrounds, Infection control education is a neglected part
may receive all or part of their clinical training of most students’ training’, * Studies that have
here. Because the hospital believed that student assessed special body substance isolation training
education about and protection from blood-borne for students have demonstrated a significant posi-
and hospital-acquired pathogens was a critical tive impact on knowledge, attitudes, and compli-
part of the clinical education process, it undertook ance after training. 3 Despite training, however,
to ensure that students receive appropriate edu- studies have shown that students may not safely
cation and screening. The burden of that process dispose sharps, use gloves appropriately, or wash
has been shared by the hospital, the training hands after removing gloves.3 In this, they imitate
programs, and the students themselves. Required the health care professionals who serve as their
PPD screening detected a cluster of PPD conver- teachers.
sions in medical students, which is currently being
evaluated; additional instruction on avoiding oc- References
cupational exposure to tuberculosis has been 1. Choudhury RP, Cleator SJ. An examination of needlestick
added to the curriculum. injury rates, hepatitis B vaccination uptake and instruction
on “sharps” technique among medical students. J Hosp
Although the hospital provides education on
Infect 1992;22:143-8.
infection control and blood-borne pathogens, it 2. Nichol KL, Olson R. Medical students’ exposure and
does not give formal instruction on intravenous immunity to vaccine-preventable diseases. Arch Intern Med
catheter placement or phlebotomy. Such a pro- 1993;153:1913-6.
gram could be undertaken by the student’s school, 3. Doebbeling BN. Li N, Lansing JS, Knudson R, Albanese MA.
Universal precautions training: impact on knowledge,
or by the hospital in conjunction with the student’s
attitudes and compliance of medical students. [Abstract
school. 11901. In: Programs and abstracts of the 31st interscience
The hospital provides hepatitis vaccination free conference on antimicrobial agents and chemotherapy.
of charge to all employees with potential blood- Washington, DC: American Society for Microbiology, 1992.

I Correction
I
In the Centers for Disease Control and Prevention “Guideline for Prevention of Noso-
comial Pneumonia” (AJIC AM J INFECT CONTROL 1994;22:247-92), several errors appeared.
On page 247, the affiliation of Ronald L. Nichols, MD, is erroneously listed; it should be
Tulane University School of Medicine. On page 248, under “BACTERIAL PNEUMONIA,”
reference 1 should not be cited in the first two sentences of the opening paragraph and the
first sentence of the second paragraph. On page 254, column 2, in the last sentence in that
column, “administration of antimicrobials” should not appear in the list of host factors. On
page 270, item III.A.l.e, the recommendation “CATEGORY II” should be replaced with
“UNRESOLVED ISSUE.” Also on page 270. item III.A.2.c the recommendation, which
should be “CATEGORY ZB, ” was omitted. Please make a note of these corrections.