BioWARN, LLC

Perspective on Nosocomial Infection Control

Gregory D. Luther, VP—Product Development

September 19, 2005

Introduction
BioWarn, LLC, has discovered a breakthrough method for the detection of dangerous pathogens and is working on a final
proof-of-concept to be completed during the summer of 2005. This revolutionary, patent-pending technology—called
SmartSand™—integrates proven bio-science and micro-electronics in a new way that provides immediate alerts to the
presence of toxins, bacteria, or viruses and relays their identity to a local area network—all from a unit the size of a grain
of sand. The potential applications for SmartSand™ are numerous and are of interest to any enterprise, industry, or
public authority involved in assuring the safety and health of large numbers of people and the air, food, water,
mail/packages, environmental surfaces, and/or equipment they come into contact with in the normal course of work or
play. Initial target markets for SmartSand™ are healthcare, food processing, and bio-defense. Potential products
include:
• Hand-held units for use by nursing staff, inspectors, infectious disease specialists,
• Point-of-care bedside diagnostics in hospitals and clinics,
• HVAC inserts to monitor buildings for outbreaks such as Legionnaire’s Disease or bio-terror agents,
• Surgical dressings, monitoring for bacterial infection,
• Surgical gloves, monitoring for presence of contagion during procedures or routine patient care,
• Contagion monitors embedded in food processing plants—ahead of where the public is placed at risk,
• Inserts in the walls of shipping containers to monitor for terrorist threats,
• Inserts in dental prosthetics or surgical implants (e.g. hip replacements) for long-term infection monitoring,
• Face masks or breathalyzers to screen international travelers for contagious diseases.

In this paper we focus on just one area, but one of critical importance: reducing or eliminating nosocomial infections in
healthcare facilities. If nosocomial infection were tracked by the Center for Disease Control, it would rank number six on
the list of leading causes of death in the U.S. in 2002—ahead of diabetes, influenza, pneumonia, and Alzheimer's. The
always-on pathogen surveillance capability of SmartSand™ represents a quantum leap for the field of infection
control and could transform the state of patient safety in our hospitals.

73,000 deaths, and close behind accidents at 107,000

I. Background
It's estimated that in the United States alone there are
about 2 million nosocomial (i.e. hospital-acquired)
infections each year, of which about 90,000 result in a
patient's death. That places nosocomial infection at
number five in the list of the top ten leading causes of
death in the U.S. in 2002, ahead of diabetes at about
deathsi.
• From 1975 to 1995 the rate of nosocomial
infections per 1,000 patient days increased 36% -
from 7.2 to 9.8.
• It is estimated that in 1995 nosocomial infections
cost $4.5 billion and contributed to one death
every 6 minutes.ii The current incidence of

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Copyright © 2005 BioWarn, LLC
 nosocomial mortality is most likely higher because An effective program to combat infections includes
of the tremendous increase in antibiotic-resistant contact precautions, as recommended by the
bacterial infections. Centers for Disease Control and Prevention (CDC),
which are used when an infectious agent is present
• Morbidity and Mortality Report found that that can be spread by skin-to-skin contact or by
nosocomial infections cost $5 billion annually in contact with contaminated surfaces. According to
1999iii, which represents a $500 million increase in noted infectious disease expert Barry M. Farr, MD,
four years. The annual cost of nosocomial hospital epidemiologist for the University of Virginia
infections might now be on the order of $5.5 Health System, contact precautions are a necessary
billion. condition for the control of infection outbreaks, but
they are probably not sufficient in themselves.
• It is estimated that nosocomial infections have
Neither, for that matter, are measures based on
increased the system-wide average length of stay
antibiotic restriction, substitution, and cycling. In
(ALOS) by between 7.4 to 9.4 days, increased
order for these measures to be effective, hospitals
ICU stays by 8 days, increased morbidity by 35%,
should adopt active culture surveillance measures
and increased total cost per patient for those
together with contact precautions in a concerted
patients who survived by approximately $40,000.iv
infection control program. Active culture
A key driver of this problem is the rise of multi-drug surveillance involves the detection and tracking of all
resistance and the continued ascendancy of patients who are asymptomatically colonized with
"superbugs" such as methicillin-resistant Staphylococcus MRSA, VRE, or some other infectious agent (i.e.
aureus (MRSA), vancomycin-resistant enterococci (VRE) "colonization" means the microorganism is present in
and penicillin-resistant Streptococcus pneumoniae (PRSP). or on the body but does not cause illness; whereas
MRSA infection rates, for example, have doubled in a infection means the organism is present and disease
decade and represent half of all S. aureus infections. A has been caused).
systematic literature review covering 55 studies
published
Table 1 - Costs of nosocomial infections and infection control interventions - based on 55 published
between studies from 1990-2000 (Source: AJIC)
1990-2000 Attributable Costs of Remediation
calculated mean
(US$ per bacteremia)
mean + 1 std dev
Intervention Costs (US$)
mean mean + 1 std dev
Times Return on Intervention $
mean mean + 1 std dev
the average Nosocomial Infection (in general) 13,973 31,971 1,138 2,580 12X 12X
attributable by Body Site
costs of #1 - Bloodstream 38,703 41,825 5,622 14,688 7X 3X
#2 - Pneumonia 17,677 38,132 was cost-saving n/a
infection #3 - Surgical site 15,646 29,466 27 n/a

(i.e. directly Urinary tract infection No studies available 1,962 n/a

resultant by Pathogen
MRSA 35,367 38,282 4,808 8,176 7X 5X
excess costs Note: MRSA accounted for 54% of all S. aureus infections in ICUs in 1999, and
- 24% of nosocomial S. aureus pneumonias
incurred - 40% of nosocomial S. aureus bloodstream infections
- 49% of nosocomial S. aureus surgical site infections
versus a
Tuberculosis No studies available 61,446 148,338
control Measles No studies available 41,087 n/a
group of Varicella zoster virus No studies available 27,377 52,689
Other No studies available 27,497 62,065
patients)
and compared them to the costs of infection controlv: Farr explains that colonized, asymptomatic patients
As shown in Table 1, the costs of an infection are far more important than infected patients in the
outbreak are very substantial and far out-weigh the evolution of an epidemic. He says, "The hospital
costs of infection control. thinks it will deal with (an infection) when they get an

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Copyright © 2005 BioWarn, LLC
outbreak, get the results from clinical microbiology, then, is to reduce the cost—and so reduce the
and put (infected) patients in isolation. (But) the barrier to adoption or usage—of active culture
majority of colonized patients will not be identified surveillance. And that is the promise of BioWarn's
with that approach… Patients who are recognized by SmartSand technology.
clinical microbiology represent the tip of the
iceberg."vi Active surveillance gets past the tip and
detects the much larger, invisible portion of the
"iceberg"—those patients and healthcare workers who
Bacteria or Virus
are asymptomatically colonized. Most of an infection's
spread comes from these clinically inapparent, Ligand
Electrochemical
colonized patients, who represent most of the signal

reservoir for transmission. Surveillance cultures to

identify this reservoir are, therefore, critically
important to the control of spread—together with
effective barrier precautions—and such a concerted
approach has been shown to reduce the spread of Bio-
MRSA by 16-fold compared with standard Sensor
precautions.
BioPore

Many studies confirm that contact precautions work

when sufficient active-surveillance cultures are (Note: Depicts SmartSand detector at grain-of-sand scale.)

undertaken to detect the reservoir for spread. The

largest and most important was the Study of the
Efficacy of Nosocomial Infection Control (SENIC) a
study done by the Centers for Disease Control and
Prevention in the 1970s and the 1980s on a II. BioWarn and SmartSand™
probability sample of hospitals throughout the
BioWarn's mission is to bring
country. It showed that the intensity of surveillance
full-time, always-on pathogen
was the most powerful predictive factor with
surveillance and protection
respect to the control of infections to a lower
within the reach of every
level.vii
healthcare facility by embedding
its SmartSand™ technology in
The Problem and the Opportunity
familiar healthcare systems and
As was illustrated in Table 1 above, hospital devices and by providing new
administrators recognize that nosocomial infections categories of highly affordable
create longer hospital stays and generate costs three detection products that
times greater than normal. But in spite of research safeguard patient safety.
data indicating that contact precautions used on
their own have little or no impact on controlling 1. What Is SmartSand?
infection, most health-care facilities have not yet tried
SmartSand™ is a patent-pending bio-chip technology
the concerted approach. Instead, many hospitals are
that can detect dangerous substances in real time—
opting for low-frequency use of culture surveillance
and at a fraction of the cost of alternative
(e.g. monthly rather than weekly), or no use at all. A
technologies or techniques. Its characteristics include:
high impact improvement opportunity in any
healthcare facility's infection control process,
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Copyright © 2005 BioWarn, LLC
• Each detecting unit can be as small as a grain of
sand.
• Each unit has a bioscience component and a
microelectronics component.
• The bioscience component contains complex
organic molecules (ligands), discreetly “waiting.”
¾ They “wait” for “targets” (toxins, bacteria, or
viruses) to appear and interact.
¾ Interactions release a very small
electrochemical signature unique to the
“target.”
¾ Multiple “target” types can be detected by a
single detector.
The microelectronics component within a SmartSand
unit is comparable to chips in disposable cameras.
• More mature than nano-technology, i.e. it's 1000
times larger.
• Electrodes acquire the “target’s” signature.
• The signature is processed, identifying the
“target.”
• False-alarms are sorted and discarded before
alerts are transmitted.
• The wireless alert transmission is facilitated via
other circuitry in the unit.
• The unit uses background energy (cell phones,
RF, etc.) as a power source.
• Only communication devices are required as
external equipment.
2. SmartSand™ Benefits
Unlike other sensor technologies that detect
substances using tags, “labels”, and secondary effects
(e.g. like chemiluminescence), SmartSand™ performs
direct measurement of a target pathogen’s chemical
reaction within the detector.
Copyright © 2005 BioWarn, LLC
• By detecting, digitizing, and storing the unique
voltage patterns produced by each target
pathogen, SmartSand™ enables a precision and
sensitivity of detection not possible with
competing technologies.
• By integrating target protein detection,
digitization, and voltage pattern-matching into
one device, SmartSand™ removes the typical
separation of the bio-chip from its reaction-
detection hardware and eliminates laboratory
process steps requiring human intervention.
• By combining pathogen detectors with wireless
network communications features, SmartSand™
enables the deployment of automated, on-line,
real-time pathogen surveillance systems
anywhere that the presence or spread of disease is
a major concern.
When fully developed, SmartSand™ will deploy all of
these capabilities in a unit no larger than a grain of
sand.
III. Product Design Goals
As implied by BioWarn's mission statement, the
primary goal to be considered is that of increasing the
usage-intensity of active culture surveillance in
healthcare facilities, and enhancing infection control
process performance generally wherever failure points
can be found. As illustrated in Chart 1, a common
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source of failure across the infection control process By deploying such SmartSand™-based devices a
is the absence of a feasible control step that assures healthcare facility would be achieving three key
the quality of the infection counter-measures. But a objectives all at once:
SmartSand™-based device can be designed and
produced to fill this gap at multiple points in the 1. SmartSand™ devices would increase the
infection chain, for multiple pathogens, and for effective frequency of culture sampling to
multiple types of disease vectors. For example, "always-on," and so the coverage of a
SmartSand devices could facility's infection reservoir could be
take the following forms:

− SmartSand™ Chart 1 — The Chain of Infection and Points of Control Failure

"breathalyzer" for
screening of
Hospital
respiratory illnesses at Infection Counter- Points of
BioWarn
Improvement
hospital admissions; Vectors measures Failure Opportunities

− USB-enabled Patients Patient

Isolation
Usually only applied
to infected patients,
Use SmartSand™
devices to identify
not colonized patients colonized patients
SmartSand™ The Infection
Reservoir Gloves

sampling probes for Visitors Personal

Protective
Mask Inconvenient for staff
and no ready way to
Use SmartSand™
devices to flag PPE
Equipment Gown verify efficacy
use with laptop Infected Individuals
Health-
failures

computers in wards or care

Workers
Hand
Staff fall back to old
habits and no ready
Use SmartSand™
devices to verify
Colonized Individuals Hygiene
in the field; Community
way to verify efficacy compliance

Environ-
− Secure Digital- or The Infection Reservoir
mental Sanitation/
Sterilization
No ready way to
verify surfaces are
Use SmartSand™
devices to flag
Surfaces clean surface contamination
Bluetooth-enabled Infected Individuals

SmartSand™ Colonized Individuals Equipment

Active
Other measures
ineffective without
Use SmartSand™
devices to reduce
Surveillance
& Devices
sampling probes for of Cultures
this, but generally not
used due to expense.
cost and increase
usage of active
surveillance.
personal digital
assistants (PDAs);
− SmartSand™ -enabled surgical/examination increased substantially.
gloves, gowns, and masks; or
2. The cost of sampling and infection detection
− SmartSand™-enabled general purpose wipes.
would be dramatically reduced, and so a key
barrier to the adoption of active culture
surveillance would be removed.
Because a SmartSand™ unit is an integrated circuit
chip, it can be mass-produced at the low cost per unit 3. The efficacy of infection control
characteristic of such chips. Depending on the countermeasures—like hand hygiene or
specific features, it may be possible to provide a environmental surface sanitation—would for
SmartSand™ detection product at no more than the the first time be made measurable and
cost of a standard stethoscope, i.e. around $150 per verifiable, allowing the rapid identification
unit. And as is the case for stethoscopes, at that price and reduction of infection control errors.
there is no reason that any healthcare worker —or
patient—should be without a SmartSand™ The targeted outcomes listed in Table 1.1 provide a
device. basis for comparing SmartSand™-based pathogen
surveillance with a conventional laboratory-based
approach, which is discussed in Section V below.

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Copyright © 2005 BioWarn, LLC
 Table 1.1 — SmartSand™ Advantages Targeted Outcomes

• People — By combining pathogen detection with wireless • Increased patient safety (lower
network communications, SmartSand enables the observed rates of infection)
deployment of automated, on-line pathogen surveillance
• Reduced cost and drain on staff time
systems that a) greatly reduce the cost of staff time and
training, and b) substantially reduce the scope for error.

• Process — By integrating target (pathogen) detection, • Increased patient confidence in

signal digitization, and signal pattern-matching into one healthcare facility safety
device, SmartSand™:
• Reduction or elimination of
¾ Eliminates laboratory process steps requiring human
laboratory-based process steps
intervention,
¾ Substantially reduces time-to-detection, and so • Reduced time-to-detection and to
enhances the ability to isolate infection in a patient sequestration
population and differentiate it in individuals

• Technology — By detecting, digitizing, and storing • Reduced time-to-diagnosis and

unique signal patterns produced by target pathogens, prescription
SmartSand™ provides a precision of rapid-detection not
possible with alternative approaches. • Increased patient safety (lower rates
of infection spread)
¾ Increased specificity allows for more rapid
identification of “drug of choice” remedies that would
otherwise take hours or days to analyze

The following is a description of active culture

IV. Approaches to Infection Control surveillance in a neonatal ICU at University of
Virginia Health System in Charlottesville, VAviii:
The cost of conventional infection control
The average daily census in the neonatal intensive
As mentioned above, an effective program to combat
care unit was 24 infants per day. The estimated
infection includes contact precautions, as described
number of cultures per infant per week was three
and recommended by the Centers for Disease Control
and a half. Every infant had three cultures (nares,
and Prevention (CDC). They include:
axilla and groin) and some infants had additional
• Patient isolation • Appropriate patient cultures if a wound was present or the umbilicus
transport had not healed. Active surveillance cultures were
• Glove use
performed for 46 weeks. The estimated total
• Strict hand hygiene • Dedicated use of non-
number of infant surveillance cultures was 3864.
critical equipment
• Gown use Eighteen were positive and the remaining 3846
• Adequate cleaning and
• Mask use were negative. Three hundred and twenty-five
disinfection of shared
personnel cultures were performed and two were
equipment
positive.

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Copyright © 2005 BioWarn, LLC
Based on data Table 2 - Costs of Active Surveillance of Cultures
culled from this (Source: "Cost-effectiveness of controlling MRSA," Journal of Hospital Infection (2002) 51: 126-132)
Estimated Costs of
study, for many Description Quantity/Work Labor/Materials Estimated Costs per Unit
Negative Positive Culture
hospitals the key Culture

barrier to adoption Nurse sample collection time 3.0 minutes per sample 20.00 dollars per hour $ 1.00 $ 1.00
(wages)
of active culture
Disposable lab supplies 1.0 negative culture 2.74 dollars per negative $ 2.74
surveillance may culture
1.0 positive culture 4.62 dollars per positive $ 4.62
simply be the high culture
cost. As shown in Lab technician time 10.0 minutes per 17.00 dollars per hour $ 2.83
Table 2, the cost of negative culture (wages)
15.0 minutes per 17.00 dollars per hour $ 4.25
active culture positive culture (wages)

surveillance is Cost per culture $ 6.57 $ 9.87

mostly attributable of which lab-related 85% 90%

to laboratory staff Number of surveillance 3.5 per patient-week

Number of cultures per sampling 3.0 per patient-sample
time and Number of cultures per patient- 10.5 Cost per patient-week $ 69.02 $ 103.64

materials—85% to
90% in this case.

And as shown in Table 2.1 - Costs of Active Surveillance of Cultures

(Source: "Cost-effectiveness of controlling MRSA," Journal of Hospital Infection (2002) 51: 126-132)
Table 2.1, when Description Quantity/Work Estimated Costs of Estimated Costs per Unit
Negative Positive Culture
multiplied by the Culture

number of beds to Beds to be surveilled 100

Cultures processed per 1050.0
be surveilled, the week for weekly
costs of a surveillance

laboratory-based, Percent of cultures testing 0.47%

positive (based on UVA
full-time, facility- example)

wide active culture Number of cultures testing

positive (based on UVA
surveillance example) 5 cultures per week $ 9.87 per positive culture $ 49.35
program can run
into the millions of Percent of cultures testing
negative 99.53%
dollars per year for
Number of cultures testing
a large hospital. A negative 1045 cultures per week $ 6.57 per negative culture $ 6,869.13

500 bed facility, for Total weekly cost for 100 patients surveilled weekly $6,918

example, would
spend about $1.8
million per year in
staff time and
laboratory materials to support a weekly regimen of
active culture surveillance. Similarly, a hospital
wishing to spend less than $500,000 per year could
only afford a monthly surveillance regimen, and the
cost of a daily surveillance regimen would exceed $12
million per year—a cost no hospital could afford.
Estimated annual cost for 100 patients surveilled weekly $ 360,000
Estimated annual cost for 500 patients surveilled weekly $ 1,800,000
1. SmartSand-based, always-on pathogen
detection
Given the high cost of lab-based active culture
surveillance, three of the SmartSand™ features are
particularly valuable: its small size, its always-on
capability, and its low cost.

Because of SmartSand™'s small size, it can be

deployed as a variety of hand-held or smaller devices,
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Copyright © 2005 BioWarn, LLC
or it can be embedded in existing devices or
equipment.
Because of its always-on capability, SmartSand™
provides the equivalent of full-time culture
surveillance—not just daily, or even hourly—but
minute-to-minute surveillance that a lab-based process
cannot deliver. The impact of the "always-on"
capability on patient safety is very significant because
reducing the frequency of surveillance increases the
chance that the reservoir of infection represented by
colonized patients will go undetected—and
uncontrolled—for longer. As shown in Table 2.2, in
a 500 bed hospital with 25,000 admissions per year,
monthly surveillance would only have a 1-in-4 chance
of identifying a colonized but asymptomatic patient.
Always-on culture surveillance brings 100% coverage
and minimizes the chance that an incoming patient
will contract an infection from a reservoir resident in
the hospital.
Table 2.2 - Chances of Detecting Contagion
for Annual Admissions of… 10,000 25,000
Number of Hospital Beds 500 500
Patients/Bed per Year 20 50
Chance of Identifying a = 1 in 1.7 = 1 in 4.2
Colonized Patient w/ Monthly
Surveillance
Chance of Identifying an = 1 in 0.4 = 1 in 1.0
Colonized Patient w/ Weekly
Surveillance
As was stated earlier, the common point of failure
across the infection control process is the absence of
a control step that assures the quality of the infection
counter-measure. In other words—short of sampling
and culturing every surface, device, and person and
sending it to the lab throughout the day—there is no
reasonable way to check that a sanitation or
sterilization step worked as intended, that hand-
hygiene has been observed by everyone at a patient's
bedside, or that visitors entering a hospital are not
Copyright © 2005 BioWarn, LLC
carriers of MRSA or some other contagion. A critical
benefit of the SmartSand™ technology to a healthcare
facility is that it makes the infection control
process verifiable, measurable, and therefore,
manageable to a degree not otherwise possible. And
that represents a quantum leap for the field of
infection control.
V. Analysis
A comparison of infection control process outcomes
is summarized in Table 3 below. Overall, the always-
on pathogen surveillance capability provided by
SmartSand™ increases the chance of detecting a
patient colonized with a "super-bug" to100% for a
fraction of the cost of lab-based culture surveillance.
That translates into greatly improved patient safety,
and eventually, into growing confidence in the
community that hospitals are safe places in their own
right.
Of all the improvement opportunities that
SmartSand™ could be used to address in a healthcare
facility, the biggest may be the chronic under-use of
active culture surveillance in our hospitals.
The major cost savings that SmartSand™ would bring
is in the reduction or elimination of the laboratory-
based steps from the infection control process, which
account for over 85% of the total process cost. Of
the estimated $260,000 of residual cost in this
example, SmartSand™ devices and consumables only
account for 18%. That means that further
opportunities for efficiency improvement lie more
with the methods of sample collection than with the
cost of the SmartSand™ devices, and those
opportunities may be realizable through products that
embed SmartSand™ detectors in surfaces and
equipment—like hospital bed-rails, respirators, and
catheters—in order to provide continuous sampling.
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VI. Conclusion nosocomial infection from the list of top-10 causes of
death in America.
By removing cost as the key barrier to the adoption of
active culture surveillance, and by improving the
performance level from weekly or monthly
surveillance (or none) to always-on pathogen
surveillance, SmartSand™ has the potential to be the
key innovation allowing our healthcare system to
bring nosocomial infection under control and remove

Table 3 — Outcome Comparison

Conventional Lab-
Targeted based Culture
Outcomes Surveillance SmartSand™-based Surveillance

People

Increased patient • Can reduce the failure • Always-on SmartSand™ pathogen surveillance
safety (lower costs of infection by a increases the chance of detecting a colonized patient
infection rates) factor of 7 to 12 times. to100% for a fraction of the cost of lab-based culture
surveillance.

Reduced cost and • Increases staff costs, • Substantially reduces or eliminates both staff and
drain on staff time particularly in the lab. materials costs in the lab, which account for ~90% of
over all cost.
• May be able to reduce cost of sample collection by
embedding SmartSand™ in existing equipment.

Process

Increase patient • Would improve • Visible presence of SmartSand™ always-on pathogen

confidence in confidence, but may not surveillance devices/products demonstrates innovation
hospital safety be financially feasible and reinforces patient and community confidence.

Reduced time-to- • Culturing of samples • SmartSand™ detection is immediate.

detection takes 1 to 2 days.

Technology

Reduced time-to-
• Culturing of samples • SmartSand™ detection is immediate, and its high level
diagnosis and
takes 1 to 2 days. of specificity can accelerate time-to-diagnosis.
prescription

Increased patient
• Culturing of samples • The potential for spreading a contagion over a two day
safety (lower rates
takes 1 to 2 days. period is eliminated for every colonized patient
of infection spread)
identified.

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Copyright © 2005 BioWarn, LLC
 References:
* * * * *
BioWarn, LLC, is currently selecting corporate
partners to collaborate on the design and testing of
SmartSand™-based products. We are looking for
partners who have a deep understanding of the
markets for pathogen detection, established
relationships with key buyers in this field, experience
with developing medical devices/products and gaining
regulatory approvals for them, and a strong reputation
for innovation and customer-focus. Jointly, we can
develop SmartSand™ product prototypes that can
be rapidly integrated with existing marketing
channels to tap the multi-billion dollar market
opportunities for rapid pathogen detection
technologies.
This prototype development process will include:
• Choosing pathogens to be detected
• Establishing background contaminant levels and
warning thresholds
• Developing SmartSand™ end-user product
designs (e.g. handheld devices, HVAC system
inserts, etc.)
• Integrating the network communications
approach (wireless, onboard, LAN, etc.)
• Estimating production costs to support business
and marketing strategy development
Please contact Dr. Jeff Riggs, President and COO,
BioWarn, LLC, to discuss your needs and to explore
these exciting market opportunities. (Telephone
number 301-926-9050.)
Copyright © 2005 BioWarn, LLC
iN C H S - FASTATS - Deaths/Mortality.
www.cdc.gov/nchs/fastats/deaths.htm (Accessed
August 21, 2005). The list is as follows:
1. Heart disease: 696,947
2. Cancer: 557,271
3. Stroke: 162,672
4. Chronic lower respiratory diseases: 124,816
5. Accidents (unintentional injuries): 106,742
6. Diabetes: 73,249
7. Influenza/Pneumonia: 65,681
8. Alzheimer's disease: 58,866
9. Nephritis, nephrotic syndrome, and nephrosis:
40,974
10. Septicemia: 33,865
Weinstein RA. Nosocomial Infection Update.
ii
Special Issue. Emerging Infectious Diseases. Vol 4
No. 3, July Sept 1998.
Forth Decennial International Conference on
iii
Nosocomial and Healthcare-Associated Infections,
Morbidity and Mortality Weekly Report (MMWR),
February 25, 2000, Vol. 49, No. 7, p. 138.
iv1. Press Ganey. “Press Ganey Knowledge
Summary: The Cost of Nosocomial Infection.”
(2003). www.pressganey.org (Accessed July 8,
2005).
v Stone PW, Larson E, Kawar LN. A systematic
audit of economic evidence linking nosocomial
infections and infection control interventions:
1990-2000. Am J Infect Control 2002;30:145-52.
Infection Control Today - 05/2003: "Stricter
vi
Precautions."
vii Ivanhoe's Medical Breakthroughs -
"Unnecessary Illness: Four Steps to Save Patients'
Lives -- Full-Length Doctor's Interview."
http://search.ivanhoe.com/ (Accessed July 18,
2005)
Karchmer TB, Durbin LJ, Simonton BM, Farr
viii
BM. Cost-effectiveness of active surveillance
cultures and contact/droplet precautions for
control of methicillin-resistant Staphylococcus
aureus. J Hosp Infect. 2002 Jun;51(2):126-32.
_________
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