The infection control practitioner: an action plan for the 1990s

Some articles have suggested that to survive in the 1990s an infection control practitioner (ICP) will have to be "smarter, brighter, or gone"--they assume that new initiatives for hospital peer review (utilization review, risk management, antibiotic use review, and quality assurance) soon will swallow up the ICP and the infection control program. This article questions that assumption. It reviews data supporting the continuing need for hospital infection control programs and presents information suggesting that the need for the ICP will increase rather than decline during the 1990s. Four essential characteristics for infection control programs are listed, and skills that make the ICP a valuable resource for other peer review programs are described. Several ways that the ICP can (and must) bring this information to the attention of other hospital personnel are suggested. Such actions help assure recognition of the continuing important role of the ICP and the hospital infection control program in each U.S. hospital and long-term care institution.     

Cardiac catheterization laboratory imaging quality assurance program.

With the recent approval of the National Electrical Manufacturers Association (NEMA) standard for "Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance," comprehensive cardiac image assurance control programs are now possible. This standard was developed by a joint NEMA/Society for Cardiac Angiography and Interventions (SCA&I) working group of imaging manufacturers and cardiology society professionals over the past 4 years. This article details a cardiac catheterization laboratory image quality assurance and control program that includes the new standard along with current regulatory requirements for cardiac imaging. Because of the recent proliferation of digital imaging equipment, quality assurance for cardiac imaging fluoroscopy and digital imaging are critical. Included are the previous works recommended by the American College of Cardiology (ACC) and American Heart Association (AHA), Society for Cardiac Angiographers and Interventions (SCA&I), and authors of previous image quality subjects.     

Quality control in hemodialysis: quality assurance process

The development of a quality assurance step in hemodialysis replies to the needs of the accreditation process defined in the hospital reform and the related ordinances edited in April 1996. This global concept is set to continuously improve the quality care and the outcomes of the hemodialysis patients. The thought behind this work has two objectives: provide guidelines to guaranty quality and adequacy of hemodialysis treatment schedule in ESRD patients; anticipate standard rules edited by regulatory authorities for quality indices and control process in hemodialysis. The final aim of this work is also to demonstrate that the quality assurance process in hemodialysis should not be perceived as an extra administrative burden but rather as a new opportunity to establish good medical practice rules in the peculiar domain of renal replacement therapy.     

Perceptions and misconceptions regarding the Joint Commission's view of quality monitoring

The Joint Commission recently has revised its hospital standards for infection control to reflect more accurately current state-of-the-art practices. In addition, the Joint Commission's Agenda for Change initiatives include the development of clinical indicators; one of the topics that will be included in those clinical indicator sets will be infection control. How the hospital chooses to organize itself to conduct the historically required monitoring and evaluation of clinical patient care currently required by the standards of the Joint Commission is at the option of the hospital. How the hospital will organize and collect data specific to infection control indicators yet to be developed by the Joint Commission has not been determined and will not be defined until specific research and development projects are completed. The hospital is expected to have in place infection prevention, surveillance, and control programs; it also is expected to have in place a quality assurance program that focuses not only on solving identified problems but also on the improvement of patient care quality. How the hospitals organize and/or integrate these activities is also at its option. It is expected that qualified professionals will direct and enforce infection prevention, surveillance, and control practices; indicators for infection control can provide data that will help assess the relative success of those practices and activities. The Joint Commission is not developing the capability to judge, on its own part, the actual quality of care provided by an organization seeking accreditation. Rather, the Joint Commission is committed to developing more accurate means to evaluate the structures, processes, and outcomes of diagnosis and treatment activities, as well as their interrelationships. Clinical excellence is supported by quality in the organizational environment and the managerial and leadership contexts within which patient care is delivered. Both clinical and organizational excellence are essential components of quality, and the Joint Commission is convinced that it is appropriate and timely to undertake more direct assessments of both.     

A program for infection surveillance utilizing an infection control liaison nurse

Today's infection control programs require a practical, efficient, and effective surveillance system. The Epidemiology Section of a 650-bed, university-affiliated hospital has implemented a two-phase approach. Phase I is surveillance by service. Each service receives a minimum of 2 months' concentrated surveillance, with critical care units monitored each month. The entire hospital is covered within a year. Monthly statistics are issued for each surveyed service and the individual patient units within that service. Phase II involves the infection control liaison nurse (ICLN). An ICLN, established in each patient unit, monitors infection control practices and acts as a liaison between the unit and the epidemiology section. Selected candidates are trained by the epidemiology section. The ICLN aids in more immediate identification of problems and better monitoring of aseptic practices. This approach is effective and manageable. Better understanding of unit problems result in more relevant educational programs with time to conduct additional activities. Statistics have more meaning and support for infection control is improved.     

PDCA循环在医院感染管理质量控制中的应用效果分析

目的评价PDCA循环在医院感染管理质量控制中的应用效果。方法回顾性分析我院2013—2016年医院感染管理质量控制工作,对比分析PDCA循环采用前后医院感染发生率、多重耐药菌检出率、管理制度依从率和知晓率以及消毒、灭菌效果。结果 PDCA循环采用前后医院感染发生率分别为2.05%和1.67%,4年间多重耐药菌检出率分别为1.38%、1.30%、1.07%、0.90%,呈下降趋势。采用PDCA循环后医院感染管理制度依从率和知晓率较采用前显著提高,且空气、物体表面及医务人员手等的消毒效果也明显好于采用PDCA循环之前。结论在医院感染管理质量控制中应用PDCA循环能够明显提高医护人员的制度依从率,提高消毒、灭菌质量合格率,降低医院感染的发生率和多重耐药菌的检出率。     

An algorithm for the control of nosocomial varicella-zoster virus infection

Inadvertent or uncontrolled introduction of varicella-zoster virus into the hospital environment occurs commonly and must be investigated in a systematic and efficient manner to minimize secondary spread to patients (particularly the immunocompromised) or hospital personnel. On the basis of a review of the literature and our practical experience with 11 such exposures to varicella-zoster virus during a 2-year period, we have developed a working algorithm for such investigations. Index cases most often are children, resident physicians, students, young nurses, and ancillary personnel, or adult patients with herpes zoster. A negative or uncertain past history of this infection is an unreliable predictor of susceptibility among the exposed and should be confirmed by serology tests or delayed hypersensitivity skin testing. An incubation-contagion timetable, coupled with a stratification of risk among the exposed, permits a prioritized response in dealing with an introduction of varicella-zoster virus. The preemployment screening of all hospital workers for susceptibility to varicella-zoster virus should be considered as a practical and cost effective policy.     

A quality assessment tool for tuberculosis control activities in resource limited settings

Tuberculosis (TB) is a significant problem, infecting nearly 9 million new patients per year and killing about 2 million a year. The primary means with which to affect TB globally are to decrease transmission locally, mainly by effective identification, diagnosis, and treatment of infectious TB patients. Therefore, quality assurance of TB control efforts at the local level is essential. This study describes the creation of a data extraction tool for retrospective chart review based on the International Standards for TB Care, 2009 for the assessment of TB control programs located in resource limited settings. The tool was field tested at a rural mission hospital in central Kenya. Results were used by host site staff to develop a quality improvement plan. The process prompted revision of the tool to clarify questions and answers. This is a tool that can be used in resource limited settings for data collection to assess the quality of TB care and to inform the design, implementation, and further assessment of future quality improvement initiatives.     

Practical risk-adjusted quality control charts for infection control

BACKGROUND: Control chart methodology has been widely touted for monitoring and improving quality in the health care setting. P charts and U charts are frequently recommended for rate and ratio statistics, but their practical value in infection control may be limited because they (1) are not risk-adjusted, and (2) perform poorly with small denominators. The Standardized Infection Ratio is a statistic that overcomes both these obstacles. It is risk-adjusted, and it effectively increases denominators by combining data from multiple risk strata into a single value. SETTING: The AICE National Database Initiative is a voluntary consortium of US hospitals ranging in size from 50 to 900 beds. The infection control professional submits monthly risk-stratified data for surgical site infections, ventilator-associated pneumonia, and central line-associated bacteremia. METHODS: Run charts were constructed for 51 hospitals submitting data between 1996 and 1998. Traditional hypothesis tests (P values <.05) flagged 128 suspicious points, and participating infection control professionals investigated and categorized each flag as a "real problem" or "background variation." This gold standard was used to compare the performance of 5 unadjusted and 11 risk-adjusted control charts. RESULTS: Unadjusted control charts (C, P, and U charts) performed poorly. Flags based on traditional 3-sigma limits suffered from sensitivity <50%, whereas 2-sigma limits suffered from specificity <50%. Risk-adjusted charts based on the Standardized Infection Ratio performed much better. The most consistent and useful control chart was the mXmR chart. Under optimal conditions, this chart achieved a sensitivity and specificity >80%, and a receiver operating characteristic area of 0. 84 (P <.00001). CONCLUSIONS: These findings suggest a specific statistic (the Standardized Infection Ratio) and specific techniques that could make control charts valuable and practical tools for infection control.     

Risk assessment towards tuberculosis among hospital personnel: administrative control, risk exposure, use of protective barriers and microbial air quality

A recent increase in the rate of tuberculosis among hospital personnel has led to a greater concern about the risk of Mycobacterium tuberculosis transmission in the hospital. A cross-sectional study was conducted to assess the risk of tuberculosis infection among hospital personnel of a governmental hospital in Bangkok by applying hospital tuberculosis control strategies, including administrative control, risk exposure, use of protective barriers when in contact with TB patients, and microbial air quality in the studied wards. Fourteen members of the infection control committee (ICC) and 118 hospital personnel were interviewed regarding the infection control policy and its implementation. The history of TB exposure at work and the use of protective barriers when in contact with TB patients were recorded for the studied hospital personnel. Air samples in the studied wards were collected to investigate bacterial and fungal counts. The results reveal that all the studied ICC members and more than 85% of studied hospital personnel knew the infection control policy and attempted to implement it. However, 35.71, 37.50, 80.90,93.93, and 88.46% of personnel working in ER, OPD, ICU, female medical ward, and male medical ward, respectively, implemented the TB isolation policy. More than 80% of studied personnel had histories of exposure to TB patients, but only 52.73% (31.57% in OPD to 80.00% in ICU) used the appropriate barriers (N95) when in contact with TB patients. Air samples collected from the studied wards, except ICU, had high bacterial and fungal counts (> 500 cfu/m3). These findings show that hospital personnel working in the studied wards, except ICU, were at risk for tuberculosis infection. The hospital ICC should advertise the use of TB standard precautions to hospital personnel and provide a ventilation system for reducing the microbial counts in the air of the studied wards.     

The development of systematic quality control method using laboratory information system and unity program

Quality control (QC) process is performed to detect and correct errors in the laboratory, of which systematic errors are repeated and affect all the laboratory process thereafter. This makes it necessary for all the laboratories to detect and correct errors effectively and efficiently. We developed an on-line quality assurance system for detection and correction of systematic error, and linked it to the Unity Plus/Pro (Bio-Rad Laboratories, Irvine, USA), a commercially available quality management system. The laboratory information system based on the client-server paradigm was developed using NCR3600 (NCR, West Columbia, USA) as the server and database for server was Oracle 7.2 (Oracle, Belmont, USA) and development tool was Powerbuilder (Powersoft Burlignton, UK). Each QC material is registered and gets its own identification number and tested the same way as patient sample. The resulting QC data is entered into the Unity Plus/Pro program by in-house data entering program or by manual input. With the implementation of in-house laboratory information system (LIS) and linking it to Unity Plus/Pro, we could apply Westgard's multi-rule for higher error detection rate, resulting in more systematic and precise quality assurance for laboratory product, as well as complementary to conventional external quality assessment.     

我国医疗卫生机构和结核病防治工作者结核感染控制的现状及建议

关于我国医疗卫生机构和结核病防治工作者结核感染控制的信息和有关资料比较少.近年来,我国在结核感染控制方面做了一些工作,编写了《中国结核感染预防控制手册》和《中国结核感染控制标准操作程序》,开展了一系列培训和调查研究.研究发现我国大多数地区还未开展规范的结核感染控制工作,医疗机构缺乏专职或兼职的结核感染控制人员,结核感染控制经费不足,一些医疗卫生机构建筑设计和功能分区不符合结核感染控制要求,医务人员个人防护用品配备不足并且使用不正确.结核病防治工作者结核分枝杆菌感染和患病率较高,主要与职业暴露有关,而且,医务人员对结核感染控制知晓水平一般.鉴于医疗卫生机构和结核防治工作者结核感染控制现状,我国应加强结核感染控制工作,制定结核感染控制政策,加大对医疗卫生机构感染控制的经费投入,建立系统的医务人员结核感染控制和患病筛查制度,并加强结核感染控制相关知识的教育和培训.     

The hospital tuberculosis registry: an aid to infection control

Maintenance of a "central tuberculosis registry" has been proposed to facilitate communication between hospital personnel and other persons such as members of health departments and practicing physicians involved in the care of patients. A 5-year experience revealed additional benefits: (1) recognition, and partial correction, of deficiencies in tuberculin testing; (2) recognition and termination of a pseudoepidemic of false positive acid-fast bacilli smears; (3) increased frequency with which patients were placed in respiratory isolation at the time of admission to the hospital; and (4) decrease in the indicence of tuberculin conversions among hospital employees. It is suggested that such a registry should be included in all hospital infection control programs.     

Autopsy: its role in clinical quality control in the elderly in the 1990s

The accuracy of pre-mortem diagnosis was investigated in 100 patients (age range 65-97 years) undergoing autopsy. Post-mortem rate was 22%. In 32% of cases there were discrepancies between ante- and post-mortem diagnosis; in 14% these may have affected therapy or outcome. We conclude that autopsy remains a useful tool in clinical quality control, and should be part of a quality assurance plan in all geriatric units.     

我国血吸虫病防治项目管理与质量控制工作重点

本文围绕血吸虫病防治项目管理与质量控制工作, 总结了我国血防项目工作中的3种主要管理模式, 以及在国家法规、 国家规划、 国家标准和规范3个层面指导下的系统管理机制。通过灭螺工程的实例分析, 指出开展科学评估、 确保每项防治工作的质量是当前我国血防管理模式中值得探讨的问题之一。提出认真抓好血防项目管理的每个环节, 科学制定各项防治工作的操作规程, 规范防治专业人员工作流程, 是血防工作绩效考核的前提, 也是保证各项防治措施实施质量、发挥其应有防治效果的关键。     

Improved patient care using the A/S/G/E guidelines on quality assurance: a prospective comparative study

The American Society for Gastrointestinal Endoscopy has promulgated guidelines on quality assurance in gastrointestinal endoscopy. Thorough documentation of endoscopy reports and a peer review process were strongly recommended. We evaluated 1408 dictated endoscopy and colonoscopy reports for deficiency in reference to the guidelines during three periods: 6 months before (group 1), 6 months after the application of the guidelines (group 2), and 5 months of intensive peer review process (group 3). Deficiency was defined as lack of documentation of at least 1 of the 10 parameters that should be included in endoscopy reports according to the guidelines. There was a significant decrease in deficiency rates in groups 2 (91.6%) and 3 (32.7%) compared with group 1 (99.8%) (p less than 0.01). Peer review and direct confrontation of the endoscopists with their deficiencies significantly reduced the use of inappropriate indication for endoscopy (1.5%/group 3 vs. 5.2%/group 1, p less than 0.01). Adherence to the A/S/G/E guidelines on quality assurance improved documentation, decreased inappropriate use of endoscopy, and may thus improve quality of care.     

Survey of infection control training program graduates: long-term care facility and small hospital practitioners

Graduates of a 2-day basic training course in infection control were surveyed. Respondents were generally from Midwestern long-term care facilities and small hospitals. These infection control practitioners had multiple roles in addition to infection control, most notably employee health and quality assurance. Infection control practitioners demonstrated significant job stability. The vast majority of institutions where survey respondents were employed followed recommended infection control practices.     

Improvement of routine works and quality control in mycobacterial laboratory

Many new methods have been introduced into routine laboratory works in microbiology since 1990. Molecular biology, in particular, opened a new era and promoted a technician's skill much. PCR and hybridization technique have been ordinary one in many laboratories. Since old techniques such as smear and culture are still needed, amount of routine works is increasing gradually. Thus, improving efficiency and keeping quality of routine works are becoming more and more important issues. This symposium focused on such points, and four skilled technicians around Japan presented their own tips. 1. Coexistence of M. tuberculosis and M. avium complex (MAC) in the MGIT culture system: Yasushi WATANABE (Clinical Laboratory Division, NHO Nishi-Niigata Chuo National Hospital). Sputum samples of some tuberculosis patients yielded only MAC in the MGIT culture system. Such co-infected cases presented problems to mislead proper treatment and infection control. The detection rate of MAC was significantly high, and the growth speed of MAC was significantly rapid in the MGIT culture system, compared to those of M. tuberculosis. Additionally, M. tuberculosis was not detected with even more quantity than MAC in the small amount of mixed samples. Higher sensitivity and growth speed of MAC are the important characteristics of the MGIT system. 2. Internal quality control with ordinary examination results: Akio AONO (Department of Clinical Examination, Double-Barred Cross Hospital, Japan Anti-Tuberculosis Association). Our laboratory utilizes ordinary examination results as the internal quality control for specimen pretreatment, culture, and drug susceptibility testing. The contamination rate of MGIT culture system is useful for the evaluation of the decontamination process. It was 6.3% on average in our laboratory in 2005. The number of drug resistant strains is also useful to assess the performance of drug susceptibility testing. The incidence of each anti-tuberculosis drug resistance detected monthly in 2005 is up to 5 for isoniazid (INH), 4 for rifampicin (RFP), 7 for streptomycin (SM), 1 for ethambutol (EB), and 2 for pyrazinamide (PZA), respectively. If any serious deviation from the average number is observed, action for the investigation is taken. The analysis of the ordinary examination data is useful to implement a quality control efficiently, and to improve the total laboratory performance. 3. The advanced devices for solving problems of the smears and cultivation of Mycobacteria: Motohisa TOMITA (NHO Kinki-chuo Chest Medical Center). Recently, the newly developed, standardized, commercially available kits including PCR and liquid media for confirmation and identification of mycobacteria are prevalent in Japan for the rapid diagnosis of M. tuberculosis. These tests are sensitive and accurate, but still expensive and technically demanding. The improvement of these methods, in particular, requires time-consuming process. We have optimized the culture technique, the identification method, and the drug-susceptibility testing for Mycobacteria in a time-saving manner. They should provide a basic grounding in the application of the techniques for anyone who is interested in these intriguing bacteria. 4. Ultimate quality control of specimens--teaching how to get a good sputum sample: Takeshi HIGUCHI (Kyoto University Hospital). Modern techniques including molecular biology have been applied to routine laboratory works for rapid detection, identification, and drug susceptibility testing of mycobacteria. Even in using such techniques, however, poor quality specimens yield only poor results. To get a high quality specimen, particularly sputum samples, is very important. Therefore, laboratory technicians in our hospital have directly taught each patient how to expectorate good quality sputa since 2001. The teaching of patients has improved the rate of P1 samples from 21.5% to 36.6% by Miller and Jones visual score of sputum. The teaching has also improved the rate of smear positive P1 samples from 11.4% to 28.8%. To teach each patient how to get good sputa seems useful for keeping the laboratory quality high.