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Contents
List of Contributors ix
Preface: An Introduction to Practical Hospital Epidemiology xiii
Ebbing Lautenbach, Preeti N. Malani, Jennifer H. Han, Jonas Marschall,
Emily K. Shuman, and Keith Woeltje
vii
Contents
21 Infection Prevention in the Outpatient 26 Employee Health and Infection Control 350
Setting 238 Tara N. Palmore and David K. Henderson
Sarah S. Lewis and Rebekah W. Moehring
27 Tuberculosis Infection Control in Healthcare
22 Infection Prevention in Resource-Limited Settings 361
Settings 251 Henry M. Blumberg
Anucha Apisarnthanarak, Nuntra Suwantarat,
28 Patient Safety 380
and Virginia R. Roth
Darren R. Linkin and Patrick J. Brennan
29 Infection Prevention in Design, Renovation, and
Section 6 – Special Topics Construction 387
23 The Role of the Laboratory in Loie Ruhl Couch, Loreen A. Herwaldt, and Linda
Prevention of Healthcare-Associated L. Dickey
Infections 271 30 Regulatory Issues Concerning Healthcare
Michael A. Pfaller and Daniel J. Diekema Epidemiology and Infection Prevention 411
24 Biological Disasters 287 Stephen Weber and Pranavi Sreeramoju
Sandro Cinti and Eden Wells
25 Exposure Workups 325
David B. Banach, Hilary Babcock, and Louise-Marie
Index 428
Dembry
viii
Contributors
ix
List of Contributors
x
List of Contributors
xi
Preface
An Introduction to Practical Hospital Epidemiology
Ebbing Lautenbach, Preeti N. Malani, Jennifer H. Han, Jonas Marschall,
Emily K. Shuman, and Keith Woeltje
It is with great pleasure that we introduce the fourth edition population and the growing utilization of other healthcare
of Practical Healthcare Epidemiology. As noted by Dr. Loreen settings, (e.g., long-term acute care, outpatient, home care),
Herwaldt in the introduction to the first edition of this text, the need for the healthcare epidemiologist will continue to
“Hospital epidemiology and infection control have become increase dramatically in the coming years.
increasingly complex fields.”1 While certainly true then, it is The knowledge and skills of the healthcare epidemiologist
even more so now. The healthcare epidemiologist today faces also lend themselves extremely well to addressing many other
an abundance of both challenges and opportunities. One issues at the forefront of patient care today. Knowledge of
need look no further than the recent emergence or reemer- healthcare epidemiology is useful for antimicrobial steward-
gence of multidrug-resistant gram-negative bacteria, Middle ship, quality improvement, technology assessment, product
East Respiratory Syndrome, and Ebola, to appreciate the evaluation, and risk management. In particular, application
dynamic nature of this field. Ongoing emphasis on such of healthcare epidemiology–based practices has offered much
issues as pandemic preparedness, patient safety, and complex to the patient safety movement. These include establishing
regulatory requirements related to infection prevention, clear definitions of adverse events, standardizing methods for
highlights the need for the expertise of the healthcare epide- detecting and reporting events, creating appropriate risk
miologist in many arenas. The requirement for knowledge- adjustments for case-mix differences, and instituting evidence-
able and well-trained healthcare epidemiologists has never based intervention programs.5,6
been greater. We recognize that several comprehensive textbooks of
Healthcare-associated infections (HAIs) exact a tremendous hospital epidemiology exist as excellent resources for infec-
toll in morbidity, mortality, and costs. A recent survey esti- tion control professionals.7–9 This book is not meant to repli-
mated that 4 percent of all patients admitted to US acute-care cate these textbooks but rather to complement them as
hospitals in 2011 developed HAIs, for a total of 721,800 such a pragmatic, easy-to-use reference emphasizing the essentials
infections.2 Among these patients, about 75,000 died during of healthcare epidemiology. As a starting point, this overview
their hospitalizations. Total annual costs for the five major of the important aspects of healthcare epidemiology should
HAIs (surgical site infection, central line–associated blood- provide a good foundation for those entering the field of
stream infection, catheter-associated urinary tract infection, infection prevention. The practical nature of the book lends
Clostridium difficile infection, and ventilator-associated pneu- itself well to the very nature of healthcare epidemiology as
monia) have recently been estimated at around $9.8 billion.3 a field that requires constant action (e.g., surveillance, inter-
The primary focus of the healthcare epidemiologist remains ventions). While daily decisions must be based on a thorough
the prevention of HAIs. In this regard, there has been substan- evaluation of the data, they must also be practical in the
tial progress over the past several years, with significant reduc- context of the healthcare setting and surroundings of the
tions in the incidence of several HAIs, including central practitioner.
line–associated bloodstream infection, surgical site infection, This book is also distinguished by its focus on experience.
and C. difficile infection.4 However, as indicated by the While based solidly on the existing medical literature, this
ongoing burden of HAIs noted above, there remains much resource also offers real-world advice and suggestions from
work to be done. Indeed, the healthcare epidemiologist must professionals who have grappled with many of the longstand-
deal with all aspects of the healthcare setting to prevent ing and newer issues in infection prevention. As with earlier
patients or staff from acquiring infection. These include out- editions of this book, we asked the authors to write their
break investigation, surveillance, policy development, audits, chapters as if they were speaking to an individual who would
teaching, advice, consultation, community links, and research. be running an infection prevention program and who was just
With the increasing acuity of the hospitalized patient starting in this field. The authors’ task was to prepare future
xiii
Preface
hospital epidemiologists for their new careers by summarizing 2. Magill SS, Edwards JR, Bamberg W, et al. Multistate
basic data from the literature and by providing essential refer- point-prevalence survey of healthcare-associated infections.
ences and resources. In addition, we asked the authors to share N Engl J Med 2014;370:1198–208.
their own experiences of what works and what does not work 3. Zimlichman E, Henderson D, Tamir O, et al. Health
in particular situations. care-associated infections: a meta-analysis of costs and financial
impacts on the US health care system. JAMA Intern Med
We hope that this book will provide trainees and profes- 2013;173:2039–46.
sionals in infection prevention, particularly the fledgling
4. Centers for Disease Control and Prevention. 2014 national and
healthcare epidemiologist, the knowledge and tools to estab- state healthcare-associated infections progress report. Published,
lish and maintain a successful and effective healthcare epide- March 2016. Available at www.cdc.gov/hai/progress-report/index
miology program. Ours is a vibrant and exciting field that .html.
presents new challenges and opportunities daily. The pro- 5. Scheckler WE. Healthcare epidemiology is the paradigm for
spects for the healthcare epidemiologist are virtually limitless, patient safety. Infect Control Hosp Epidemiol 2002;23:47–51.
whether they are in infection prevention, antimicrobial stew- 6. Gerberding JL. Hospital-onset infections: a patient safety issue.
ardship, patient safety, or beyond. We hope that this textbook Ann Intern Med 2002;137:665–70.
provides the foundation upon which many future years of 7. Bennett JV, Brachman PS and eds. Hospital Infections. 6th ed.
further learning, innovation, and advancement are based. Philadelphia, PA: Wolters Kluwer, 2013.
8. Mayhall CG, ed. Hospital Epidemiology and Infection Control. 4th
References ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2012.
1. Herwaldt LA, Decker MD. An introduction to practical hospital 9. Wenzel RP, ed. Prevention and Control of Nosocomial
epidemiology. In: Herwaldt LA, Decker M, eds. A Practical Handbook Infections. 4th ed. Philadelphia, PA: Lippincott Williams &
for Hospital Epidemiologists. Thorofare, NJ: Slack Inc., 1998. Wilkins, 2003.
xiv
Section 1 Getting Started
Chapter
Ethical Aspects of Infection Prevention
Hospital epidemiologists and infection preventionists make the reservoir is a contaminated drain that is easy to replace or
countless decisions every day. In general, we do not make life- a nursing assistant with no political clout in the hospital. But what
or-death decisions, such as whether to withdraw life support or if the reservoir is a powerful physician with a large practice and
whether to withhold possibly life-sustaining therapies. Few of tremendous influence with the administration? Or what if the
our decisions require court injunctions or provide the fodder administration thinks your recommendations are too expensive
for eager journalists. We simply decide whether to isolate and excessive? Would you bow to the pressures and recommend
patients, whether to let healthcare workers continue to work, interventions that you think are less than optimal, or would you
or whether to investigate clusters of infections – all very rou- risk the wrath of the physician or the administration and state
tine decisions in the life of anyone who practices infection your best advice regardless of the consequences?
control. These decisions are so ordinary that they could not Infection prevention personnel frequently inform patients
possibly have any ethical implications. Or could they? or healthcare workers that they have been exposed to an infec-
In fact, many of the decisions we make every day, even those tious disease. When the pathogen is varicella zoster virus, the
we consider quite straightforward, are also ethical decisions – problem is relatively simple. Yet infection prevention personnel
which is to say, they compel us to choose between competing must still consider ethical issues. Do you permit some suscep-
moral values. Such choices are rarely easy, and their intrinsic tible employees to continue working, if they wear masks, but
difficulty is not eased by the fact that few of us have received restrict others? Or do you restrict all susceptible healthcare
more than cursory training in ethics. Moreover, if we attempt to workers regardless of their position or their economic status?
train ourselves, we find that very little has been written about If you are very busy at work or have plans for the evening, do
the ethics of our specialty, infection prevention and control. you delay your response or ignore the exposure altogether?
Other exposures, such as those to the hepatitis B virus, the
Common Infection Prevention Decisions human immunodeficiency virus (HIV), or the prion agent that
causes Creutzfeldt-Jakob disease, provoke emotional responses
with Ethical Implications and raise challenging ethical questions. For example, what do
We may easily overlook the ethical component of our everyday you tell employees in the pathology laboratory who were not
decisions; thus, we may misconstrue the decision confronting informed that the patient might have Creutzfeldt-Jakob disease
us, thinking that it is without ethical consequences when, in and, therefore, did not use the recommended precautions when
fact, ethical principles are at stake. Take, for example, the they processed the brain tissue? Do you recall and resterilize
practice of isolating a patient colonized with a drug-resistant instruments used for the implicated brain biopsy? Do you
organism. Isolating a patient constrains the patient’s freedom notify patients who subsequently had surgical procedures and
of movement but protects the rights of other patients to be might have been exposed to instruments that were not steri-
treated in an environment without unnecessary risk. Similarly lized in the manner recommended to kill the infectious agent?
the practice of removing healthcare workers with contagious We hope these examples enable you to see that ethical
diseases from patient care follows from epidemiologic data but considerations abound within the practice of infection preven-
also from the ethical concepts of beneficence, nonmaleficence, tion. Clearly, ethics is not the esoteric discipline some misun-
and utility – with an overall goal of maximizing good outcomes derstand it to be. Ethics is part of our daily practice. We should
and minimizing harm. In such cases, we restrict the freedom of not delegate ethical deliberations to others, though we will
healthcare workers to obtain the greater benefit of protecting need to include professional ethicists, hospital managers,
patients and fellow workers. Or, when stocking the hospital accountants, and lawyers in our discussions. We all must
formulary, we consider the efficacy and cost of drugs, but we recognize that maintaining our ethical integrity is an essential
also balance the benefit of lower cost (to the patient and the professional responsibility. This chapter is a brief introduction
hospital) and the risk of selecting resistant microorganisms to the intricate intersection of ethics and infection prevention.
against physicians’ freedom to prescribe any available drug.
Infection prevention personnel confront additional ethical
dilemmas in many of their daily activities. For example, when Taxonomy
managing an outbreak, infection prevention personnel must In the introductory paragraphs, we described some routine
identify the offending pathogen’s source and mode of transmis- infection prevention activities that have ethical implications.
sion, and then intervene appropriately. This is simple enough if These descriptions are, in essence, a “narrative taxonomy” of
1
Loreen A. Herwaldt and Lauris C. Kaldjian
ethical problems in infection prevention and hospital epide- respect to our profession. On the basis of our experience in
miology. A taxonomy is an orderly listing or categorization of infection prevention (LAH) and ethics (LCK), we developed
things. Infection prevention personnel are probably familiar a taxonomy that we think will be helpful to infection preven-
with taxonomy as it refers to microorganisms, but not with tion personnel as they think about their own work (Table 1.1).
2
Ethical Aspects of Infection Prevention
Table 1.2 Differences in emphasis between epidemiologic ethics and Table 1.3 Differences in approach between infection prevention and
medical ethics medical care in the care of a patient with a transmissible infection
3
Loreen A. Herwaldt and Lauris C. Kaldjian
Table 1.4 An approach to ethical problems in infection prevention components and is, thus, quite reactogenic. Recipients
often have significant pain, swelling, and erythema at
1. State the problem plainly
the vaccination site, and they may develop fever, anor-
2. Gather and organize data exia, irritability, and vomiting.14 In addition, some chil-
a. Medical facts dren may develop inconsolable crying, excessive
b. Goals and procedures of infection prevention and somnolence, seizures, or hypotonic-hyporesponsive
control episodes.14 Encephalopathy, which is very rare, is the
c. Interests of patients, healthcare workers, hospital, most severe complication of pertussis vaccination.14
community, and public health agencies Opponents of the vaccine allege that the vaccine not
d. Context infrequently causes serious permanent neurological
3. Ask: Is the problem ethical? damage. In some countries, such as Sweden, Japan, and
the United Kingdom, the antivaccine movements gained
4. Ask: Is more information or discussion needed? such prominence that the countries either stopped vacci-
5. Determine the best course of action and support it with nating children or the rate of vaccination decreased sig-
reference to one or more sources of ethical value nificantly. All three of these countries had outbreaks of
a. Ethical principles: beneficence, nonmaleficence, pertussis that affected thousands of children and caused
respect for autonomy, justice, utility numerous deaths.14
b. Rights: protections that are independent of The controversy over the pertussis vaccine suggests that
professional obligations the ethical debate over vaccines in both the public health
c. Consequences: estimating the goodness or arena and in the hospital revolves around providing the
desirability of likely outcomes greatest good for the greatest number of people (i.e., pro-
d. Comparable cases: reasoning by analogy from prior tecting them against harmful infections) and protecting the
“clear” cases individual from harm that could be caused by
e. Professional guidelines: for example, APIC/CHICA- a vaccination. The ethical dilemma occurs because, in gen-
Canada professional practice standards48 eral, the population benefits (i.e., an immunized population
f. Conscientious practice: preserving epidemiologists’ that is less susceptible to infection), but individual persons
moral integrity
bear the risk of vaccine complications.15–19 In highly vac-
6. Confirm the adequacy and coherence of the conclusion cinated populations, a single person can refuse a vaccine
and may avoid both the potential complications of the
NOTE: APIC, Association for Professionals in Infection Control and
Epidemiology; CHICA-Canada, Community and Hospital Infection Control vaccination and the infection itself because he or she is
Association–Canada. protected by the vaccinated population. However, one may
ask whether this is fair to persons who are willing to bear
the burdens of being vaccinated (potential
triumph are the seeds of a substantial controversy and an complications).15 Furthermore, if this scenario is repeated
ethical problem. Because use of vaccines effectively decreased often enough, the vaccination rate in the population will
the incidence of many infectious diseases, the public no longer drop, and nonimmune people will be at risk.
knows how dreadful these infections can be and how many The ethical dilemma just described also occurs in
complications and deaths they have caused. The public is now healthcare facilities that require healthcare workers to be
more aware of vaccine complications than they are of the immune to certain infections. For example, most health-
infections the vaccines were developed to prevent. care facilities require that healthcare workers be immune to
In addition, parents of “vaccine-damaged children,” the nat- rubella, which means that employees must present proof
ural health movement, television, radio talk shows, and the that they have had the infection or that they have had at
Internet have all become important participants in this least two rubella vaccinations. The reasons healthcare facil-
“debate.”10,11 ities have this requirement are that rubella is easily trans-
The controversy about the pertussis vaccine is illustra- mitted within healthcare facilities and that this virus can
tive. In the 1940s, pertussis was the leading cause of death cause severe congenital defects if a pregnant woman
among children under 14 years of age. Pertussis, in fact, becomes infected.20,21 Thus, healthcare facilities caring for
killed more children than measles, scarlet fever, diphtheria, pregnant women seek to protect these patients by requiring
polio, and meningitis combined.12 The incidence of per- staff to be immune to this infection. Pregnant employees
tussis was already decreasing before the killed whole-cell also benefit from this requirement. However, the individual
vaccine was introduced, which was probably related to healthcare provider may not benefit from receiving this
changes in social conditions, hygiene, and nutrition. vaccine, because rubella causes very mild disease in adults,
However, the incidence declined significantly after the vac- and an adult vaccine recipient might develop complica-
cine was introduced.13 tions. Thus, the hospital puts limits on the autonomy of
Because the whole cell pertussis vaccine is composed its staff members to avoid harming pregnant patients and
of dead Gram-negative bacteria, it includes many toxic employees.
4
Ethical Aspects of Infection Prevention
The approach many facilities take to influenza vaccine In this case, the individual vaccinated gets the benefit and
illustrates another extreme. The influenza virus is quite con- bears the risk associated with the vaccine. In addition, employ-
tagious and can cause serious complications, hospitalization, ees are not required to take the vaccine. If they do not want it,
and death, particularly among elderly people and people with they simply sign a waiver stating that they decline the vaccine,
significant underlying diseases. Healthcare facilities, particu- in which case they bear the risk if they are exposed to hepatitis
larly hospitals, care for many people who are at risk for com- B. The institution, thereby, fulfills its ethical and legal obliga-
plications of influenza. Moreover, outbreaks of influenza have tion to the employee, and the employee maintains his or her
occurred in healthcare facilities. These outbreaks are difficult freedom to choose whether to be vaccinated.
to recognize and, therefore, are underreported.22 Thus, many But a question remains regarding hepatitis B vaccine, and
hospitals offer the vaccine free of charge to employees each fall. that is whether all healthcare workers should be required to be
But employees, even those who work with high-risk patients, immune to this virus to protect patients from becoming
usually are not required to be vaccinated.23 In this case, hospi- infected. Given that the risk of transmitting hepatitis B virus
tals have elected not to mandate vaccination with a safe and is very low with most healthcare-associated activities, there
effective vaccine that could prevent at least as many severe does not seem to be a strong ethical argument for requiring
complications as does the rubella vaccine. Instead, they have vaccination. However, more than 400 patients have acquired
elected to preserve their healthcare workers’ autonomy rather hepatitis B from infected healthcare workers who performed
than allowing the interests of vulnerable patients to take pre- invasive procedures.25 It is, therefore, appropriate to ask
cedence over that autonomy.23 whether all healthcare workers who perform invasive proce-
Why do hospitals manage rubella one way and influenza dures that could expose the patient to the healthcare workers’
another? To our knowledge, no one has studied this issue. blood should be vaccinated against hepatitis B. Though some
However, we might speculate that society considers the birth healthcare workers might argue that mandatory hepatitis
of even one child with congenital rubella to be a tragedy. B vaccination infringes on their right to choose, we think that
By contrast, we might speculate that society is not as alarmed mandatory vaccination for this group of healthcare workers is
by the fact that thousands of elderly people die each year from ethically justifiable, given the known benefits of vaccinating
complications of influenza. Moreover, a damaged child repre- healthcare workers, the minimal risks associated with the vac-
sents many impaired life-years, whereas a frail elderly person cine, and the possible benefits to patients. Because many med-
who dies represents very few life-years lost. Furthermore, ical schools now require medical students to be vaccinated and
because influenza outbreaks in healthcare facilities are rarely the Centers for Disease Control and Prevention recommend
recognized, most hospital administrators probably feel that the vaccinating all infants, in the near future this question may
risk to the patients is very low and, thus, do not require all staff become moot.
to be vaccinated. In contrast, the hospital would face a huge
lawsuit if a woman could document that she acquired rubella Isolating Patients Who Carry or Are Infected with
while receiving prenatal care in that facility. Though these
different approaches to rubella vaccine and influenza vaccine Resistant Organisms
present major ethical issues, healthcare providers seem rela- The incidence of colonization or infection with drug-resistant
tively unaware of these issues even though they often discuss microorganisms, particularly methicillin-resistant Staphylococcus
their right to autonomy regarding vaccinations. aureus (MRSA) and vancomycin-resistant enterococci (VRE), has
We believe that healthcare workers have a moral obligation increased substantially over time. One of the primary goals for
to restrict their own freedom when it comes to complying with infection prevention personnel is to protect patients from acquir-
interventions such as influenza vaccine if in so doing they ing pathogenic organisms, including resistant organisms, from
might help preserve their patients’ health. Rea and Upshur23 other patients, the environment, and healthcare workers.
take this position in their commentary on the issue: Infection prevention personnel have several means to accomplish
As Harris and Holm wrote of society in general: “There this goal: educating staff; implementing isolation precautions,
seems to be a strong prima facie obligation not to harm others with or without active screening programs to identify carriers
by making them ill where this is avoidable.” But there is (see Chapter 7, on isolation precautions); implementing hand
a special duty of care for us as physicians not simply to avoid hygiene programs; controlling use of antimicrobial agents (see
transmission once infected, but to avoid infection in the first Chapter 19, on antimicrobial stewardship); and developing clean-
place whenever reasonable. Our patients come to us specifi- ing protocols for patients’ rooms and equipment. Of these meth-
cally for help in staying or getting well. We have not just the ods for controlling spread of resistant organisms, implementing
general obligation of any member of our community, but isolation precautions, with or without active screening, and con-
a particular trust: first do no harm.23 trolling use of antimicrobial agents have been quite controversial
The hepatitis B vaccine illustrates another approach to and are associated with significant ethical issues. We discuss the
vaccines within the healthcare setting. The US Occupational ethical implications of using contact precautions to control
Safety and Health Administration requires healthcare facilities spread of MRSA and VRE.
to offer hepatitis B vaccine to all employees who will have There are numerous reasons to prevent spread of MRSA
contact with blood and body fluids to protect them from and VRE. Both organisms can cause serious infections.26–29
acquiring this virus through an occupational exposure.24 Because MRSA and VRE are resistant to the first-line
5
Loreen A. Herwaldt and Lauris C. Kaldjian
antimicrobial agents used to treat serious infections caused by endemic; 3) data from several studies suggest that proximity to
S. aureus and enterococci, these infections may be difficult and a patient who carries MRSA or VRE is a risk factor for acquir-
expensive to treat. Moreover, if MRSA becomes resistant to ing these organisms;27 and (4) common sense suggests that
vancomycin (i.e., if the resistance gene is transferred from VRE housing infected or colonized patients in rooms separate from
to MRSA), infection with such strains might be virtually patients who do not carry these organisms should reduce
untreatable with currently available antimicrobial agents. spread of the resistant organisms.
Furthermore, MRSA infections do not replace infections Other infection prevention personnel present arguments
caused by methicillin-susceptible S. aureus, rather they are against using isolation precautions to control the spread of
added to them. Thus, in hospitals where the incidence of MRSA and VRE:29–33 1) MRSA and VRE are spreading despite
MRSA colonization and/or infection increases, the overall these precautions; 2) patients in contact precautions do not
incidence of healthcare-acquired S. aureus infection often receive the same level of care as do patients with similar
increases as well.26 If MRSA and VRE are transmitted in problems who are not in contact precautions; 3) contact pre-
a hospital, other organisms, such as Clostridium difficile and cautions may actually prevent patients from getting appropri-
gram-negative organisms that are resistant to extended- ate treatments (e.g., aggressive physical rehabilitation) or from
spectrum β-lactam agents or to carbapenems may also be being transferred out of an acute-care facility to a facility better
transmitted, indicating that the overall infection prevention suited to the patients’ needs; and 4) contact isolation creates
practice in the hospital is lax. social isolation that may impair patients’ psychological well-
Some infection prevention personnel argue that data from being.
numerous institutions document the effectiveness of aggres- Other infection prevention experts would argue that the
sive prevention and control measures.27 Infection prevention real question is not whether to invest resources in attempts to
personnel who take this position would also argue that, as control MRSA and VRE, but which means should be used to
healthcare professionals, we should first do no harm. Because control spread. The major issue in this discussion has been
MRSA and VRE harm many patients, we should do all we can whether to use intensive active surveillance coupled with con-
to prevent both transmission of these organisms and infections tact precautions to control the spread of these organisms 27,36
caused by these organisms. Therefore, infection prevention or to enhance compliance with standard precautions and hand
programs are obliged to use reasonable means to prevent hygiene.30,32 The crux of this debate revolves around differing
selection and spread of these organisms.27 interpretations of the extant data. Those who support active
Other infection prevention personnel argue, to the con- surveillance and use of contact precautions believe that the
trary, that there are numerous reasons not to invest substantial data strongly support this approach,27,36 while those who sup-
resources and time into MRSA and VRE control efforts.29,30 port enhancing general infection prevention precautions
They insist that the incidence of colonization or infection with believe either that current data suggest these measures are not
these organisms is already so high that control measures are effective30,32 or that more data are needed before hospitals
ineffective and waste precious resources. They would agree spend large amounts of money and time performing active
that aggressive measures have worked in some instances, pri- surveillance.37
marily in outbreaks, but that the data on the overall incidence As suggested in the preceding paragraphs, the major ethical
of MRSA and VRE colonization or infection indicate that dilemma with respect to using contact precautions to control
infection control efforts have failed to stop transmission. the spread of resistant organisms is that the health interests of
They also argue that many colonized patients never become patients who are not colonized or infected with a resistant
infected, colonization per se does not harm these patients, and organism conflict with those of the patients who are colonized
MRSA and VRE are neither more virulent nor do they cause or infected with one or more of these organisms. That is, the
greater morbidity and mortality than methicillin-susceptible patients who are not colonized or infected expect to be treated
S. aureus and vancomycin-susceptible enterococci. Thus, these in the safest possible environment, one that is free of organisms
patients should not be subjected to decolonization or to isola- that could complicate or prolong their hospitalizations or
tion from which they will not benefit. These infection preven- could add costs to their hospital bills. They desire to avoid
tion personnel also state that efforts to control MRSA and VRE untoward consequences or complications of hospitalization.
impair patient care and, therefore, may actually cause worse On the other hand, patients who are colonized or infected with
patient outcomes than would have occurred if the patients one of these organisms have the right to full treatment for their
were not isolated.31–33 Finally, they would argue that eradicat- medical problems, which includes receiving adequate attention
ing carriage with antimicrobial agents such as mupirocin may from staff and having access to all tests and therapies that are
actually increase antimicrobial resistance.34 necessary for their care. These patients want to avoid compli-
Infection prevention personnel who think contact precau- cations of inadequate care, such as slower or impaired rehabi-
tions are an important component of a program to prevent litation, and complications of social isolation, such as
spread of MRSA and VRE offer several arguments to support depression, anger, and nonadherence to recommendations.
their position:35 1) contact precautions have been shown by Each side in this debate refers to different ethical principles
numerous investigators to stop transmission of these organ- to support their case. Those in favor of contact precautions
isms during outbreaks; 2) contact precautions have reduced argue that this type of isolation protects unaffected patients
transmission of MRSA and VRE in situations where they are from acquiring organisms that could eventually harm them
6
Ethical Aspects of Infection Prevention
and thus supports the ethical principle of nonmaleficence. Ebola have demonstrated the ease with which such organisms
The opposition argues that use of contact precautions violates can spread in healthcare facilities. In fact, spread of these organ-
affected patients’ autonomy and may violate the principles of isms has been amplified in the healthcare setting; many patients
beneficence and nonmaleficence, as well. and healthcare workers have acquired these infections in health-
Some infection prevention leaders have begun to question care facilities, and many of these patients and healthcare workers
whether contact precautions should be used as a primary com- have died. Thus, outbreaks of these infections have shown how
ponent of a program to prevent spread of MRSA and VRE important protecting patients, visitors, and staff – infection
within healthcare facilities.38–40 They argue that most studies prevention programs’ primary responsibility – truly is.
addressing this issue are of low quality and were done before In this section, we will use the example of Ebola virus
intensive efforts to improve hand hygiene were begun or before infection to illustrate how the ethical principles of autonomy,
hospitals introduced bathing patients with antiseptics like chlor- beneficence, nonmaleficence, justice, and utility apply when
hexidine. Moreover, they argue that contact precautions do not healthcare workers care for patients infected with a highly
prevent infections in colonized patients, that contact precau- transmissible and virulent organism. We will also discuss the
tions may harm patients, that the incremental benefit of contact following additional ethical values that are relevant when
precautions is likely to be small, and that contact precautions addressing such challenging situations: altruism, solidarity,
increase costs and healthcare waste considerably.38–40 Recent and conscientious practice.
studies by Gandra et al.41 and Edmond et al.42 found that Infection prevention personnel direct much of their work
MRSA and VRE transmission rates and device-associated hos- toward preventing harm to patients, visitors, and healthcare
pital-acquired infection rates, respectively, did not change sig- workers. Thus, many routine infection prevention practices
nificantly after they stopped using contact precautions for are designed to maximize beneficence and nonmaleficence.
patients colonized or infected with these organisms. While the In contrast, some routine practices, such as implementing iso-
data are suggestive, neither study assessed whether the rate of lation precautions or restricting ill healthcare workers, place
MRSA and VRE transmission changed. Both studies had meth- explicit limits on autonomy for patients or for healthcare work-
odological weaknesses, and thus they do not provide a definitive ers. In addition, infection prevention personnel generally focus
answer to this question. most of their attention on providing benefit and preventing
Those who still support using contact precautions cite the harm to patients while at the same time ensuring that visitors
results of recent studies that did not find an increased risk of and healthcare workers are also safe. When healthcare workers
adverse events among patients treated with contact precau- care for patients with infections caused by highly transmissible
tions compared with patients who were not.43–47 In fact, the and virulent organisms, infection prevention staff members
cluster randomized trial study conducted by Harris et al. found must increase their efforts to ensure that other patients, visitors,
that universal gown and glove use by healthcare workers caring and healthcare workers are safe (nonmaleficence) and must
for patients in intensive care units significantly reduced the place more limits on patients’ autonomy. During outbreaks of
risk of MRSA acquisition as measured by routine surveillance these infections or during other crises, infection prevention staff
cultures and did not increase the risk of adverse events.45,47 may also apply the principle of utility more frequently to ensure
MRSA and VRE are the two most common resistant bac- that benefits within a healthcare population are maximized,
terial pathogens in most US hospitals. Nevertheless, as we have harms are minimized, and scare resources are preserved.
discussed in this section, experts in infection prevention still
Autonomy: The principle of respect for patient autonomy
debate the merits and the ethics of placing patients in contact
indicates that patients have the right to request and receive
precautions simply because they are colonized or infected with
available treatment even for infections caused by highly trans-
one of these organisms. This discussion also illustrates that as
missible and virulent organisms. Healthcare workers must
medical information changes, one’s ethical assessment of the
always respect the patient’s right to self-determination while
merits of infection prevention interventions may change as
balancing this right against the important interests of other
well. Consequently, hospital epidemiologists and infection
patients and of healthcare workers themselves. Because Ebola
preventionists cannot take refuge in the old adage “we’ve
virus is transmitted easily in healthcare facilities and infections
always done it this way.” Rather, we must constantly reassess
are often severe, infection prevention programs implement
the literature and then reassess our practices in light of new
more stringent infection prevention practices that necessarily
data and ethical principles.
limit the infected patient’s autonomy to protect the interests of
other patients, visitors, and healthcare workers. Thus, to protect
Ethical Issues Associated with Caring for Patients other patients and healthcare workers, healthcare facilities place
a patient with Ebola virus infection in rigorously enforced
Infected with Highly Transmissible and Virulent isolation precautions and limit the diagnostic tests and treat-
Organisms such as Ebola Virus ments offered.
Highly transmissible and virulent organisms present special Beneficence: The principle of beneficence indicates that
challenges for healthcare providers, including infection preven- healthcare workers must promote patients’ best interests.
tion staff. Outbreaks of Severe Acute Respiratory Syndrome In most situations, this means that infection prevention
(SARS), Middle East Respiratory Syndrome (MERS), and measures address primarily the patient’s welfare and that
7
Loreen A. Herwaldt and Lauris C. Kaldjian
healthcare professionals work primarily to ensure the maximize benefits and minimize risks to all persons con-
patient’s welfare when deciding which diagnostic tests and cerned, including the affected patients, other patients, health-
treatments are appropriate. When a patient is infected with care workers, and members of the community. Under usual
a highly transmissible virulent organism such as Ebola circumstances, infection prevention programs’ and health-
virus, infection prevention personnel and clinicians must care workers’ primary focus is on maximizing the benefits
increase their attention to the welfare of other patients, and minimizing the harms for individual patients while
visitors, and healthcare workers, thereby expanding the maintaining a safe environment for other patients, visitors,
extent to which the principle of beneficence is applied also and healthcare workers. However, when caring for a patient
to these groups. When trying to maximize the principle of infected with Ebola virus or with another highly transmissi-
beneficence, we should try to balance the best interests of all ble virulent organism, infection prevention programs must
concerned parties (maximizing beneficence in this way can increase their efforts to ensure that other patients, visitors,
be seen as being related to promoting utility). On the basis and healthcare workers benefit and are not harmed. In these
of the principles of autonomy and beneficence, healthcare situations, infection prevention personnel and clinicians
workers should strive to meet the patient’s needs and must consider both the likelihood that the patient will benefit
should never abandon the patient. from a diagnostic test or a procedure and the likelihood that
healthcare workers or other people will be harmed in the
Nonmaleficence: The principle of nonmaleficence indicates
process.49 For example, clinicians may choose to intubate the
that healthcare workers must avoid harming patients. This
patient and insert a central venous catheter before the
principle can be applied to healthcare workers, even during
patient’s condition deteriorates (i.e., preemptively) to
routine patient care. For example, the Centers for Disease
decrease the likelihood of harm to healthcare workers asso-
Control and Prevention introduced standard precautions to
ciated with performing procedures under emergent condi-
protect healthcare workers from the harm of acquiring patho-
tions. Or clinicians may deem the likelihood that a moribund
genic organisms while caring for infected patients, including
patient will benefit from a procedure, such as dialysis, to be
those infected with common organisms such as MRSA, hepa-
very low and the likelihood that a healthcare worker could be
titis B, hepatitis C, and HIV.
harmed to be high and, therefore, decide not to offer the
When a patient is infected with a highly transmissible and
patient this intervention.49,51 During widespread outbreaks,
highly virulent organism, such as Ebola virus, the principle of
such as the Ebola outbreak in West Africa, healthcare admin-
nonmaleficence can be seen as indicating that, in addition to
istrators, clinicians, infection prevention personnel, and pub-
protecting the patient from harm, we must also protect other
lic health officials may justifiably apply the principle of utility
patients, visitors, and healthcare workers from harm. As noted
(alongside other principles and values) to protect healthcare
previously, healthcare workers still must accept some risk
workers because healthcare workers are a limited resource
because they cannot abandon patients. Healthcare facilities
that is essential to the community’s well-being.49 To protect
and infection prevention programs must do all they reasonably
healthcare workers, it may be necessary to preferentially
can to minimize the risks for each front-line staff member by
provide them prophylaxis or treatment, and it may be neces-
providing safeguards such as optimal personal protective
sary to triage patients48 to limit healthcare workers’ exposure
equipment, education and practical training, an optimal work
to patients who are least likely to respond to treatment.
environment, and other staff members who monitor and coach
the staff members caring for the patients.48,49 Altruism: The principle of altruism indicates that healthcare
workers have a duty to care for infected patients regardless of
Justice: In general, the principle of justice indicates that
the causative organism’s transmissibility or virulence. Because
persons should have equal access to healthcare resources,
they have promised to care for the sick and to make patients’
that persons in similar situations should be treated simi-
needs their primary professional concern, healthcare workers
larly, and that available benefits or necessary burdens
are committed to responding to their patients’ needs, even
should be distributed fairly among the group of individuals
when responding entails some degree of risk to their own
under consideration. When healthcare workers must care
welfare. The basis for healthcare workers’ duty to care results
for patients infected with highly transmissible and virulent
from:
organisms, the principle of justice indicates that risks and
burdens of caring for these patients should be distributed • A professional’s promise to respond to the needs of the sick;
fairly and consistently among staff. This principle also indi- • The actual need of one or more patients;
cates that healthcare workers who do not accept this risk • The ability of an actual professional to meet that need.
have likely transferred the risk to someone else. Thus, Various professionals, organizations, agencies, employers, and
a healthcare worker who will not care for a patient with governments have assessed the extent of a professional’s duty
Ebola or who does not report to work during an influenza to care for patients during disasters or outbreaks that pose
pandemic has shifted to other healthcare workers both the serious risks to the healthcare workers’ lives. However, they
risk intrinsic to caring for the patient and the responsibility have come to very different conclusions.48–50,52,53 Some have
for not abandoning the patient.50 stated that the duty to serve is an absolute duty regardless of the
Utility: The principle of utility indicates that infection pre- healthcare worker’s risk; others have stated that the individual
vention programs and healthcare workers should work to healthcare worker can decide how much risk he or she is
8
Ethical Aspects of Infection Prevention
Table 1.5 Range of possible responsibilities based on the assessment of students, and the community. For this reason, employees of
the duty to care in a crisis situation
these facilities are considered essential and required to report
Expectation Rationale to work as scheduled, or may be called to report to work if not
scheduled.”55
Work is mandatory Duty entails accepting the Table 1.5 describes a range of possible expectations and
associated risks rationales relevant to the duty to care in situations that pose
Exceptions exist Competing duties exist that infectious or other risks to healthcare professionals.
may mitigate a particular
Solidarity: The principle of solidarity indicates that healthcare
healthcare worker’s duty to
care facilities and the community should support healthcare work-
ers who serve at risk to their own and their loved ones’ welfare.
Healthcare workers may Healthcare workers may opt As discussed previously, healthcare facilities have a duty to
volunteer; if a sufficient out of caring for patients in protect their staff (see nonmaleficence), but attention to this
number of healthcare work- risky situations; if some work-
duty is particularly important during times of crisis or high
ers do not volunteer, a lottery ers must be required to work,
anxiety associated with highly transmissible and virulent
system can be used to select a lottery system distributes
additional personnel burdens fairly organisms. The principle of solidarity indicates that healthcare
facilities should: 1) clearly articulate and actively promote the
Healthcare workers may Healthcare workers may opt applicable professional standards of duty and the institutional
volunteer, and those who do out of caring for patients in and societal expectations regarding the duty to care so that the
will receive hazard pay; if risky situations, and those
healthcare workers understand the situation; and 2) provide
a sufficient number of who volunteer should be
venues in which staff members can learn about the infectious
healthcare workers do not compensated for accepting
volunteer, a lottery system the risk; if some workers agent, the risks posed by caring for a patient infected with this
can be used to select addi- must be required to work, agent, and precautions the facility is implementing to protect
tional personnel a lottery system distributes and help staff who care for these patients. Opportunities for
burdens and compensation open dialogue between leadership and frontline staff members
acknowledges the signifi- will allow the concerned parties to calibrate and communicate
cance of the risk their expectations and also acknowledge the boundary between
consensus and controversy.
The principle of solidarity also indicates that healthcare
willing to assume; and yet others have come down somewhere
facilities have additional responsibilities when their staff mem-
between these two alternatives.
bers care for patients infected with highly transmissible and
The American Medical Association’s (AMA) Code of
virulent organisms, such as Ebola virus.48,49,52 For example,
Medical Ethics upholds the duty to care, stating: “Because of
healthcare facilities must protect the staff who care for the
their commitment to care for the sick and injured, individual
patient from discrimination, stigmatization, and harassment
physicians have an obligation to provide urgent medical care
from inside and outside the institution and must help provide
during disasters. This ethical obligation holds even in the face
for the caregivers’ physical needs (e.g., food, water, adequate
of greater than usual risks to their own safety, health or life.”54
breaks from work, a place to stay if necessary) and emotional
But the AMA Code includes a note of caution that effectively
needs (e.g., help making difficult decisions, counseling) given
appeals to the principle of utility: “The physician workforce,
the difficulty of caring for critically ill patients while wearing
however, is not an unlimited resource; therefore, when parti-
extensive personal protective equipment and maintaining con-
cipating in disaster responses, physicians should balance
stant vigilance to avoid exposing themselves to the infecting
immediate benefits to individual patients with ability to care
pathogen. Moreover, because healthcare workers who acquire
for patients in the future.”
Ebola while caring for a patient could become seriously ill and
Unlike most professional societies, some governments have
could subsequently be disabled or die, healthcare facilities
defined healthcare workers’ duty to work and treat patients
should consider developing compensation provisions for
during emergencies as being absolute. In fact, some US states
harms suffered by healthcare workers who knowingly accept
“regard the obligation to treat during an emergency as a legal
serious risks when caring for such patients (e.g., death benefits
duty punishable by criminal sanctions for failure to act or for
for surviving family members).
abandonment of patients.”48 Some employers have developed
strict policies addressing the duty to work during crises, such as Conscientious practice by staff: Conscientious practice refers to
a pandemic. For example, the University of Iowa developed the profound role that conscience, or integrity, plays in our
a policy that focuses on utility and also stipulates that the duty moral lives. It indicates that healthcare workers should
to care is extensive, given that the hospital is an essential have the freedom to determine the degree of risk that is accep-
community resource. The policy states: “The University will table given their life situations and other important responsi-
be considered a ‘community asset’ and a ‘state asset’ in bilities (such as obligations to dependents). In other words,
responding to a pandemic. University of Iowa Hospitals and healthcare workers must balance their duty to care for patients
Clinics and Student Health Services will experience increased in a particular situation against their duties or obligations to
demand for medical treatment and advice from faculty, staff, family, friends, society, and, we might say, even themselves.49,52
9
Loreen A. Herwaldt and Lauris C. Kaldjian
Respecting conscientious practice protects the individual health- Any institution that does not act as it preaches wastes time
care provider’s ability to maintain his or her integrity, and doing and also, at least implicitly, encourages unethical behavior.
so acknowledges that healthcare workers vary in their assess- Institutions reward the conduct they prize. It should be
ments of how much risk is acceptable based on their personal a warning to us that, at present, we are probably more likely
obligations and their philosophical, religious, or professional to hear of inconsiderate behavior excused on the grounds of
beliefs. a colleague’s academic or technical brilliance than to hear an
individual praised for making a difficult but ethically sound
Moving from Theory to Practice decision. Perhaps as a community we need to consider the
significance of Ralph Waldo Emerson’s startling and humbling
As should be apparent, ethical principles and values provide
remark that “character is higher than intellect.”
guidance but not absolute or detailed answers to specific ethi-
As our financial and staff resources are stressed without
cal issues. Moreover, different principles can suggest different
limit and as the pressures under which we work intensify,
and possibly competing responsibilities and may lead admin-
temptation amplifies. Barbara Ley Toffler of Resources for
istrators, clinicians, and infection prevention personnel at dif-
Responsible Management states:
ferent healthcare facilities to different conclusions based on
their patient populations, their healthcare worker population,
For many employees, being ethical is getting to be too risky –
their resources, and the guidelines and laws governing their something they can’t afford any more. . .. The problem grows
practices. When developing policies and procedures to address out of what I call the “move it” syndrome. . .. That’s when the
either routine or more challenging infection prevention issues, boss tells a subordinate to “move it” – just get it done, meet the
infection prevention personnel, clinicians, and administrators deadline, don’t ask for more money, time, or people, just do it –
must consider the implications of each principle and deter- and so it goes on down the line.58
mine which principles are most important for specific indica-
tions or situations. As new information arises, infection For American companies, this peril from within is as ser-
prevention personnel and others must evaluate whether speci- ious as outside threats from competitors. As more employers
fic policies and procedures still meet the standards implicit in are forced to “move it,” companies are increasingly vulner-
the ethical principles.9,52 For example, they may need to eval- able – legally, financially, and morally – to the unethical actions
uate whether contact precautions for patients with MRSA or of decent people trying to [move it just to keep their jobs].58
VRE infection or colonization remain an ethical practice given To “move it,” we may find ourselves declining to issue
intensive use of alcohol-based products for hand hygiene and appropriate sanctions in an outbreak because we are loath to
antiseptic solutions for bathing patients. If effective treatments alienate an important doctor or lose referrals from a powerful
are introduced for Ebola or infections caused by other highly practice group. Or, fearing management anger over bad pub-
transmissible and virulent organisms, infection prevention licity and loss of revenue, we may decide against closing a ward
personnel may need to reevaluate imitations on care offered affected by an outbreak. Under pressure to reduce budgets, we
to patients infected with these organisms.52 may approve questionable practices or eliminate effective
Ethical codes emphasize a profession’s core values and may infection prevention programs. We may be tempted to treat
help guide decisions and behavior. To our knowledge, neither influential administrators or practice groups preferentially
the Society for Healthcare Epidemiology of America nor the because they control our budgets or could curtail our pro-
Association for Professionals in Infection Control and grams. We may be tempted to recommend a particular product
Epidemiology (APIC), the two societies concerned with infec- because we have received grants from the company that makes
tion prevention, have developed codes of ethics. However, the product or whose stock we own. We may feel pressure to
APIC and the Community and Hospital Infection Control withhold information regarding resistant organisms so that we
Association–Canada (CHICA-Canada) have published can transfer patients to other institutions and shorten their
a document describing “professional and practice standards” length of stay in our hospital. Or perhaps we may be tempted to
for persons practicing infection prevention and control.56 condone altering hospital records to avoid losing accreditation.
A well-developed and clearly stated ethical code is an What can you as an individual hospital epidemiologist or
essential guide, yet it is also insufficient. A code of ethics infection preventionist do? We would recommend that you
cannot identify all of the ethical dilemmas that individual think about your job and identify the most common questions
hospital epidemiologists and infection preventionists will face you answer and decisions you make. Once you have identified
in the course of their practice. Nor, despite the fond hopes of these questions and decisions, you can try to identify the
professional school administrators, does reciting such a code at ethical choices they represent. You can then develop an
graduation guarantee ethical conduct. Alone, an ethical code approach for dealing with these issues before you face them
cannot ensure ethical behavior. It must be taught, learned, again, since it is easier to think more clearly and dispassio-
affirmed, and lived, if it is to affect our practice. As William nately when not in the middle of a crisis. When designing such
Diehl writes: “Formal codes of ethics are hot items these days. approaches, you should obtain help, if necessary or prudent,
[But one] thing is certain: any organization that requires all its from experts in medicine, law, ethics, or other appropriate
employees to review and sign its ethics code each year, and disciplines.
then does nothing else to encourage high moral behavior, is We have described but a few of the manifold ethical chal-
wasting its time on the code.”57 lenges that confront us. Against our ambitions and our fears,
10
Ethical Aspects of Infection Prevention
we must rely on our enduring values, commitments, and con- Are we seeking to keep our jobs, or are we seeking to imple-
tinual self-examination as we strive to meet the challenges ment the right interventions? As hospital epidemiologists and
posed by our work. We must ask ourselves difficult questions. infection preventionists, we must keep our attention focused
Are we serving ourselves or patients and healthcare workers? firmly on the needs of our patients and communities.
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12
Chapter
The Infection Control Committee
2 David A. Pegues, MD
committee undoubtedly will be leading or participating as coverage rates, or performance on infection control
members of the investigation team. These individuals, and process measures such as perioperative antimicrobial
not the committee as a whole, are responsible for making prophylaxis and infection prevention bundles.
real-time decisions about control measures and assessing By reviewing and discussing such data, the committee can
their impact. The committee’s role primarily should be help to identify variations in practice at the unit or
advisory and consultative, and this function is an important provider level and address barriers to achieving the goals.
part of the quality improvement process. The committee
also is likely to be engaged in preparedness planning and • Compliance with regulatory requirements.
response to emerging global public health threats (e.g., The infection control committee may need to develop
Ebola virus and MERS-CoV) as well as local community guidelines to help clinicians comply with external regulatory
threats (e.g., vaccine-preventable disease outbreak in requirements. Examples include institutional guidelines on
a susceptible population). Successful prevention and control notifiable disease reporting, consent requirements for human
of infections require careful planning, including evaluation immunodeficiency virus testing, and policies governing work
of the technical evidence supporting efficacy of an fitness and professional activities of healthcare workers
intervention, education, measurement, and monitoring to infected with bloodborne pathogens or other communicable
ensure impact and sustainability. The infection control diseases. In addition, The Joint Commission requires that
committee supports the mission of infection control by hospitals have written infection control policies and
establishing important alliances and advocacy, and procedures needed to conduct the organization’s mission
spreading and sustaining prevention and control efforts effectively. The infection control committee reviews and
throughout the hospital or health system. approves the annual infection control surveillance plan and
risk assessment and is charged with evaluating and ensuring
• Approving infection control–related policies and compliance with The Joint Commission infection control
procedures before submission to the medical board. standards, including all relevant elements of performance
It is more efficient to have working groups of experts draft and national patient safety goals.
and edit infection control policies before distributing them
• Promoting and facilitating the education and compliance
to committee members in advance of the next meeting.
of all staff in infection control policies and procedures.
New and existing policies are then summarized in the
meeting where committee members offer comments and The infection control committee plays an important role in
formal approval is sought. Once approved by vote of the developing and disseminating infection control education
committee, these policies and procedures are submitted to for employees. The committee may have primary
the medical board for approval. responsibility for content development or share the
responsibility with the education department. This includes
• Providing infection control input and guidance to ensure required infection control and bloodborne pathogen
the safety of the hospital environmental and employees. training for employees at the time of hire and annually
The infection control committee and its members share thereafter as well as role-specific infection control (e.g.,
responsibility for ensuring the safety of the hospital medical device cleaning and disinfection). In addition, the
environment, including hospital construction and infection control committee also helps to develop,
renovation activities, environmental services, sterilization coordinate, and disseminate education plans for new
and disinfection, and occupational health of employees. infection control policies and practices. Examples included
The committee should include standing members interventions that directly affect patient care (e.g.,
representing each of these departments. These members chlorhexidine gluconate bathing, catheter dressing
typically serve as liaisons to their departments and work products, nurse-driven urinary catheter removal protocols),
collaboratively with infection prevention program environmental control (e.g., disinfectant products), or
personnel on relevant infection control issues both within health and safety of employees (e.g., safety sharps devices,
and outside of the infection control committee meetings. latex-free examination gloves). Whatever the education
methods used (e.g., in-servicing, huddles, screen savers,
• Serving in an advisory capacity to senior medical and posters, email), this information should be effectively
administrative leadership of the facility. messaged to all impacted employees. In these ways, the
The committee serves an important advisory role to senior committee acts as a facilitator between other departments to
leadership, informing them of infection control risks and improve implementation of new infection control practices.
hazards and proposing interventions to address these issues.
• Compliance with benchmarks. Responsibilities of the Chair
The infection control committee should periodically The chair is most often a physician who has training and
review compliance with facility-specific and national expertise in infectious diseases and healthcare epidemiology.
infection prevention benchmarks. These may include The chair provides scientific and administrative leadership to
employee hand hygiene compliance and seasonal influenza the committee and is typically appointed or approved by the
14
The Infection Control Committee
medical board. The chair is responsible for reviewing the Administrative Matters
membership list annually to ensure adequate representation
Committee meetings should be held at a recurring day, time,
from appropriate departments and for replacing members who
and location with a frequency typically ranging from monthly to
have poor attendance, are unable to fill their role, have
quarterly. The agenda should be planned and distributed to
accepted different positions, or have left the organization.
committee members before the meeting. In addition, all policies
The chair also may appoint special subcommittees or task
should be distributed before the meeting to allow adequate time
forces or ad hoc members to address specific infection control
for review and comment by committee members and to improve
issues that arise.
meeting efficiency. As a token of appreciation to members, food
To be effective, the chair should be familiar with and utilize
and/or beverages should be provided, budget permitting.
effective meeting practices. These include attention to meeting
The meeting agenda may begin with introduction of new
preparation, facilitation, participation, and evaluation.
members or visiting attendees and then correction and
An effective chair, along with his/her administrative support,
approval of the minutes of the previous meeting. This may be
organizes meeting logistics and distributes the agenda and
followed by invitation for the members to provide brief, infor-
documents that require review before the meeting. The chair
mal reports or “check ins,” as appropriate. Old business should
ensures that meetings start and end on time, and keep to the
be limited, as much as possible, to updating progress toward
agenda. For example, the meeting may open with an optional
completing action items from prior meetings and to ongoing
members “check in,” in which members are invited to contri-
outbreak investigations or response to public health emergen-
bute immediate concerns to the opening of the meeting. This
cies. A healthcare infection surveillance summary is presented,
“check in” serves to bring busy people to the purpose of the
including infection counts, rates, and benchmark performance
meeting so that they can receive support or put issues aside for
and opportunities for improvement are discussed. Brief, 5-to-
the meeting. The chair must be an effective facilitator, listening
10 minute department-specific infection control reports are
attentively and respectfully, and he/she should encourage the
presented on a recurring schedule and should be summarized
participation of many members in the discussions. Verbally
in the minutes and the reports attached (Table 2.1). New
summarizing decisions and assigning action items helps to
business should focus on in-depth reports of selected current
avoid misunderstandings and moves the agenda forward.
infection prevention and control issues activities. These
Minutes record the decisions of the meeting and the actions
reports can be presented either by standing or ad hoc members
for follow-up and help to ensure that the plans and actions
or invited guests. Finally, new and revised policies should be
decided upon by the committee are implemented.
discussed and approved on an ongoing basis to ensure policy
In addition to these administrative functions, the chair
content is current and that regulatory requirements are met.
serves as an expert consultant to the hospital and departments
on infection control and prevention matters. The chair typi-
cally acts as spokesperson for the infection control committee Meeting Minutes
when reporting to the medical board and other hospital-wide
Well-documented minutes should be kept of each committee
committees and often is called upon to justify to senior leader- meeting. These minutes have four major purposes: to serve as
ship the evidence supporting the committee’s infection control communication tools, instruments for guiding current and pro-
recommendations, and their potential costs and benefits. posed infection prevention and control practices, legal and reg-
ulatory documents, and historic records. Minutes are useful to
Responsibilities of the Members notify or remind individuals of the tasks assigned to them and the
Members of the infection control committee should be selected timelines, and to report actions and decisions to the medical
both for their willingness to serve and for their ability to work board, senior leadership, and other relevant committees (e.g.,
collaboratively on committee activities. Members should quality improvement and patient safety). Minutes are important
attend the meetings regularly and, when unable to attend, tools for collaborative project management, moving projects for-
should identify a delegate to attend in their place. Members ward with the aid of well-written summaries of progress and
need to be effective communicators, as they must bring for- commitments. Infection control committee minutes are consid-
ward infection control–related concerns and report back com- ered to be confidential peer review documents in most states and
mittee activities and decisions for those whom they represent. therefore are not subjected to subpoena. Regardless of applicable
Ideally, members should be in a position of influence and have law, committee minutes are reviewed by regulatory and accred-
decision-making capacity for their departments to facilitate iting agencies, and they must be accurately and objectively
implementation and compliance with infection control poli- reported and recorded. An institution-specific template is typi-
cies and practices. In addition, many members of the commit- cally used for recording the minutes, and content is guided by the
tee have important committee reporting functions. Table 2.1 agenda. The minutes should include sections for each topic dis-
lists the reports that are often presented to the committee cussed, which contain the following information: a discussion,
during meetings and the corresponding responsible committee which is the analysis of the problem or data; a recommendation,
member. Not all reports or responsible members are applicable which describes improvement strategies; an action, which
in all healthcare settings. The frequency of these reports will includes what is to be done and how; and follow-up, which
vary but should occur no less than annually and more often, describes who is responsible for what and when this issue will
depending on the local needs. be revisited to ensure improvement has occurred.
15
David A. Pegues
16
The Infection Control Committee
Suggested Reading
for Healthcare Epidemiology of America. tae/148582/team_meetings.html. Accessed
Friedman C, Barnette M, Buck AS, et al.
Infect Control Hosp Epidemiol 1999;20: October 16, 2015.
Requirements for infrastructure and
695–705. Schirling J. Effective meeting management.
essential activities of infection control
and epidemiology in out-of-hospital Pigeon Y, Khan O. Leadership lesson: tools In: Gassiot CA, Searcy VL, Giles CW, eds.
settings: a consensus panel report. for effective team meetings – how I learned The Medical Staff Services Handbook:
Association for Professionals in Infection to stop worrying and love my team. Available Fundamentals and Beyond. 2nd ed. Sudbury,
Control and Epidemiology and Society at www.aamc.org/members/gfa/faculty_vi MA: Jones & Bartlett Publishers; 2011.
17
Chapter
Product Evaluation
3 David A. Pegues, MD
1. Organize a product selection and evaluation team: 6. Obtain samples of products under consideration.
a. Organizations should designate a team to guide the 7. Develop a product evaluation survey form:
selection, evaluation, and implementation of infection- a. This form must contain the information necessary to
prevention devices. This team is usually implemented as make informed decisions for final product selection.
a formal, standing product-evaluation committee or Criteria may include safety, performance, quality,
designated subcommittee. efficiency, ease of use, compatibility with other
b. Assign responsibility for coordinating the process products; clinical effectiveness; financial impact
and obtain input from persons with clinical expertise analysis; sterilization parameters; regulatory
(e.g., Environmental Services director for surface requirements; standardization; environmental impact;
disinfectants, critical care nurse specialist for central and training requirements.
line dressings). b. The form that is easiest to complete is usually one or two
pages and allows users to circle or check responses using
2. Set priorities for product consideration:
standardized scoring criteria, such as use of a graded
a. Define priorities based upon the facility’s rates of opinion or Likert-type scale (e.g., strongly agree, agree,
healthcare-associated infections, needlesticks, and other disagree, strongly disagree).
data, such as audits of device maintenance practices for c. Allow space for comments. Healthcare personnel should
defects in processes of care. be given an opportunity to comment on a device.
3. Gather information on the use of the conventional Individual comments can provide useful insights and
(existing) device: identify areas for further questioning.
d. Include questions about product users. Unless a product
a. Must obtain information on use of the conventional evaluation is confined to a single unit and/or group of
product (device) that it is replacing. staff, information on the respondents (e.g., occupation,
b. Frequency of use and purchase volume. length of employment and/or work in the clinical area,
c. Purpose(s) for which device is used. training on the new device) is helpful in assessing how
d. Compatibility issues with other devices it is used with different groups react to the new device.
(e.g., chlorhexidine gluconate and skin care products;
central venous catheter (CVC) lock solutions and CVC 8. Develop a product evaluation plan:
integrity). a. Select clinical areas for evaluation. Include patient-care
e. Unique clinical needs. If yes, representatives from these areas with unique or compelling clinical and at-risk
areas should be included in the team. populations (e.g., intensive care units for products
focused on device-associated infections).
4. Establish criteria for product selection and identify other
b. Determine the duration of evaluation. Consider
issues for consideration:
frequency of device use and learning curve to become
a. Design criteria – physical attributes of device, required familiar with the device. Balance staff interest with need
features for clinical needs. for sufficient product experience. If more than one
b. Performance criteria – how a device functions for its product is being evaluated, use the same population and
intended patient care and safety needs. trial duration for each product.
c. The product’s environmental impact should also be c. Plan for staff training. Healthcare personnel
assessed, including whether the product will be recycled participating in an evaluation must understand how to
or reused (e.g., isolation gown) and what method is used use the new device properly. Training should be tailored
for disposal (e.g., high-level disinfectant requiring to the audience needs and include discussion about why
stringent handling and disposal). the change is being proposed, how the evaluation will
proceed, and what criteria will be used to evaluate
5. Obtain information on available products from the
product performance (e.g., ease of use, end-user
following sources:
preference, durability, performance of device)
a. Primary peer-reviewed literature, when available. d. One efficient approach to training is to utilize a team
b. Evidence reviews from an evaluation organization, such consisting of in-house staff and device manufacturer’s
as University HealthSystem Consortium and ECRI representatives
Institute.
c. Professional resources, including professional societies 9. Compile data from the survey forms:
(AORN, APIC, SHEA) and the product manufacturers. a. Depending on the number of staff involved and survey
Manufacturers’ representatives can provide clinical and forms completed, this can be done either by hand or by
technical data, including product research, material use of a computerized database. It is useful to score
safety data sheets, and cleaning and disinfection/ each question in addition to the overall response,
sterilization methods, as appropriate. particularly if evaluating two or more devices;
d. Opinions and experience of materials management and responses to each question can be used to compare
colleagues in other similar facilities. devices. In addition, categorize individual comments so
19
David A. Pegues
they provide a better picture of the clinical experience Table 3.1 Comparison of differences between medical devices and drugs
with the device. that impact evaluation of clinical efficacy
10. Perform financial impact analysis: Results vary with operator Results unrelated to provider
skill and experience skill and experience
a. Should be performed on each product and can help to
clarify the choice between different products with Limited premarketing assess- Extensive premarketing
equivalent performance and functionality. ment of safety and efficacy assessment of safety and
b. This analysis should include direct costs (e.g., cost of the efficacy
replacement product), indirect costs (e.g., costs Low-quality evidence base High-quality evidence base
associated with the use of the device after purchase,
including training, disposal, time analysis) and group
purchasing organization contract pricing.
medical devices and products do not require such evaluation.
11. Select and implement the preferred product: Some of the differences between medical devices and drugs are
a. Learning reports from the education and training of staff outlined in Table 3.1. About half of medical devices that are
on the evaluation units are invaluable in spreading use of marketed each year are considered low-risk products (e.g.,
the product and standardizing practice across patient- bandages, surgical drapes) and are exempt from premarketing
care areas. review. New products that have undergone incremental change
b. Interdepartmental and health system standardization to a previously marketed version (e.g., dialysis catheters, endo-
plan should be developed for each product being scopes) are considered medium-risk. For these products, the
evaluated. Standardization can reduce cost and decrease FDA requires only a premarketing notification application
variations in practice that contribute to medical errors. (510 k), because they are assumed to be essentially equivalent
It also reduces inventory and storage requirements and to those already approved.6 Because the data are not required,
user training. manufacturers have little incentive to undertake studies to
answer relevant clinical questions, including the impact of
12. Perform postimplementation monitoring: devices on reducing the risk of healthcare-associated infec-
a. New product performance and user satisfaction should tions. As a result, many manufacturers rely upon data from
be evaluated at planned intervals, including the in vitro studies or laboratory model systems to support claims
frequency and criteria for reevaluation. This may of efficacy in reducing healthcare-associated infections.
correspond to the length of the contract.
b. At the provider level, monitoring should focus on
compliance and satisfaction with use of the product. Making the Business Case/Cost
c. At the unit and hospital level, it is important to assess Effectiveness
whether the product has been associated with the
If a change in product that may be more expensive but provides
desired clinical outcome and if not, why not. In the case
clinical value is being proposed, it must be shown that the
of devices that impact the risk of healthcare-associated
product will achieve the desired results (e.g., reduce infections,
infections, use of surveillance data can help to inform
produce a better clinical outcome).7 Optimally, cost/benefit
these periodic evaluations, especially when correlated
analysis should include the facility’s actual costs and revenue.
with data on compliance with product use.
For example, the difference between reimbursement for
patients and the actual hospital costs associated with patients
is their contribution margin. If the product being evaluated is
Assessing the Evidence aimed at reducing surgical site infections (SSIs), then one
When available, evidence from peer-reviewed medical litera- should compare the contribution margin for those patients
ture should be utilized when evaluating the clinical efficacy of with SSIs versus those without this complication. That differ-
a medical product and the data quality, consistency, limita- ence (delta) provides data on actual costs and can be compared
tions, and potential biases should be considered.5 However, the with clinical/healthcare-associated infection data to determine
Food and Drug Administration’s (FDA) regulatory policy is whether change is warranted.
largely responsible for the rapid introduction and large quan- Another method to assess cost effectiveness of an infection
tity of medical devices coming to market and the lack of clinical control product is to compare direct cost avoided in preventing
efficacy data for the majority of these devices. While all new infections to the incremental cost of the product. Reductions in
drugs must undergo rigorous premarketing testing in rando- rates of the targeted healthcare-associated infection can be
mized clinical trials to receive FDA approval, most new estimated from pilot evaluations within the facility and from
20
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“Ruth, I love you; can’t you love me?”
“Love you!” Her eyes closed for a moment as though she no
longer dared to look at him. Her resistance to him had relaxed; now
she thrust back from him again; but he did not permit it. He
overpowered her, drawing her against him. So she opened her eyes.
“The war’s over, Gerry.”
“Thank God, Ruth!... I couldn’t let myself even dream of this
before, dearest.”
“You mustn’t say that!”
“Why not?”
“We’ll all be going back soon, Gerry—those of us who’ve lived—
back to what we’ve been before. That’s why I kept you waiting so
long. I had to change to this.” She looked down at her dress and he
released her a little to glance down also, wonderingly.
“Why? What about it, dear?”
“It’s my own—the only thing of mine you’ve ever seen me in; I
used to wear this at the office where I worked. You know, I told you.”
“I wondered why I loved you more than ever before, Ruth. Oh, silly
sweetheart! You think you’re going back to an office!” He laughed,
delightedly.
“No; we must think the truth, Gerry. We’ve been moving in
madness through the war, my love!”
“Ah! You’ve said that!”
“I didn’t mean it! We mustn’t imagine that everything’s to be
changed for us just because we’ve met in war and——”
“And you’ve saved me, Ruth!”
“You saved me, too!”
“Oh, we shan’t argue that, dear. But about not being changed—
well I’m changed incurably and forever, my love. I mean that! You’ve
done most of the changing too. Did you think you’d made me an
American only for duration of the war?”
“But Gerry, we must think. You’ll go home and have all your
grandfather’s buildings and money and——”
“You’ll have all, too, and me besides, dear—if you want me? Do
you suppose that all these months I haven’t been thinking, too? Do
you suppose I’d want you for a wife only in war? I want you, Ruth—
and I’ll need you even more, I think, to help me in the peace to
come. But that’s not why I’m here. I want you—you—now and
forever! Can I have you?”
“You have me,” Ruth said. “And I—I have you!”
*** END OF THE PROJECT GUTENBERG EBOOK RUTH OF THE
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