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Essential Resources for Effective Infection Prevention and Control Programs: A Matter of Patient Safety - A Discussion Paper

1.0 Executive Summary

The purpose of this document is to describe, using an evidenced-based approach, the resources necessary for Infection Prevention and Control Programs across the continuum of care in acute, long-term, ambulatory and home care settings. The intrinsic and explicit values of Infection Prevention and Control Programs are researched and presented from both human and economic perspectives.

Policy makers and administrators are committed to providing comprehensive, accessible, and affordable health care services of high quality for all Canadians. Changes in the Canadian health care system and in the demographics of the population have significantly affected the availability, quality, and ultimately the safety of health care services in Canada.

The mandate of an Infection Prevention and Control Program is to prevent and control health care associated infections. Examples of health care associated infections include bloodstream, surgical site, urinary tract, pulmonary, and skin and soft tissue infections. Other infectious diseases, including respiratory (e.g., severe acute respiratory syndrome or SARS, influenza, tuberculosis) and gastrointestinal (e.g., Clostridium difficile colitis, Norovirus) infections, and infections with antibiotic-resistant organisms (e.g., methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus) transmitted in health care settings are also considered health care associated infections.

Many patient factors increase a patient’s risk of developing health care associated infections including advanced age, prematurity, and increasingly complex treatment modalities in both hospital and out-of-hospital settings.

Restructuring has occurred within the Canadian health care system, as it has in both the United States and Europe. Changes in nurse staffing numbers and staff mix related to restructuring have been associated with an increased risk for health care associated infections and have contributed to the deterioration in both quality and outcome of patient care throughout North America and Europe.

The emergence of new infectious agents such as the severe acute respiratory syndrome coronavirus (SARS-CoV) and the re-emergence of community-acquired communicable diseases such as group A streptococcal disease, community-acquired methicillin-resistant Staphylococcus aureus , and multi-drug resistant tuberculosis are also causes of concern for Infection Prevention and Control Programs.

Other concerns include infections due to contaminated drinking water (e.g., E. coli O157:H7), food borne infections (e.g., Salmonella), zoonoses (e.g.,plague), and the potential for bioterrorism events.

Evidence has been published in support of having an effective Infection Prevention and Control Program. The landmark Study on the Efficacy of Nosocomial Infection Control (SENIC) project estimated that one-third of health care associated infections in the hospital setting could be prevented if hospitals instituted the essential components required for Infection Prevention and Control Programs. Recent data regarding Infection Prevention and Control Programs in Canada (Quebec and Ontario specifically), the United Kingdom, Italy, Belgium, Australia, and the United States have reported deficits in the essential resources and components of current Infection Prevention and Control Programs.

To meet its infection prevention and control mandate, staffing, training, and infrastructure requirements are needed. However, administrators may be tempted to reduce the infection prevention and control budget as it consumes resources and does not generate revenue.

Infection prevention and control is a critical component of patient safety, as health care associated infections are by far the most common complication affecting hospitalized patients. The human and economic burdens that health care associated infections place on Canadians and their health care system speak to the importance of an effective Infection Prevention and Control Program.

1. 1 Recommended Resources and Activities for an Effective Infection Prevention and Control Program

Infection Prevention and Control Programs should be staffed appropriately to meet the goals of the Program.
Infection Prevention and Control Programs should have access to expert resources including an infectious disease physician and/or a medical microbiologist. These consultants should be reimbursed for their time and expertise.
To support the surveillance activities and to identify and manage outbreaks, Infection Prevention and Control Programs should have readily available access to microbiology and virology laboratory diagnostic services. This includes access to qualified reference laboratories that can provide timely molecular typing.
An effective Infection Prevention and Control Program should collaborate and consult with internal (e.g., patient safety, quality assurance, reprocessing, occupational health) and external (e.g., other facilities and local, provincial/territorial and national health agencies) partners to ensure appropriate communication and sharing of information.
Health care organizations should ensure that surveillance of both infection prevention and control processes and outcomes related to health care associated infections is performed; and that the data are analyzed appropriately, provided to front line staff, clinical leadership and administrators, and used to monitor and improve related patient outcomes.
Infection Prevention and Control Programs should conduct ongoing educational programs for health care providers (including volunteers, family members and students) to reinforce current standards of infection prevention and control practices, emphasizing the importance of hand hygiene.
Infection Prevention and Control Programs should have access to current infection control literature, textbooks, journals, standards and/or guidelines, in addition to Internet access.
Infection Prevention and Control Programs should have adequate office space and secretarial, data entry and computer support.
Health care organizations should ensure that there is adequate nurse staffing with the appropriate skills to apply infection prevention and control measures when providing patient care. Other health care providers in all settings where health care is delivered (e.g. respiratory therapists, physiotherapists) should also have the skills to apply infection prevention and control measures when providing patient care.
Health care organizations should ensure that there is adequate housekeeping staff with the appropriate training to provide a clean and safe environment for patient care.

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2.0 Introduction

This document describes the human and economic burdens of health care associated infections (HAIs) as well as the appropriate resources and activities required for an effective Infection Prevention and Control Program (IPCP), to minimize the incidence and adverse outcomes of these infections. Recent experience with the severe acute respiratory syndrome (SARS) and Clostridium difficile associated diarrhea outbreaks demonstrates the negative impacts of HAIs and how such infections may contribute to poor patient outcomes, disrupt patient care, as well as negatively impact the larger national economy. The goals of IPCPs are to minimize these and other negative effects by

contributing to patient safety through protecting patients from infections;^(1;3-8) protecting health care workers and visitors to health care facilities from infections;^(3;4;6) and
accomplishing these goals in the most cost effective manner whenever possible,^(4;6) thus reducing the economic impacts of HAIs on individual health facilities, health systems and the national health care industry.

Health care associated infections occur in relation to health care interventions including invasive, diagnostic, surgical, and medical procedures. Examples of HAIs include bloodstream, surgical site, urinary tract, pulmonary, and skin and soft tissue infections. Transmission of infectious diseases, such as SARS, tuberculosis, influenza, Clostridium difficile (C. difficile), Norovirus, and antibiotic resistant organisms (e.g., MRSA [methicillin-resistant Staphylococcus aureus] and VRE [vancomycin-resistant enterococci]) to patients within the health care delivery system are also considered HAIs.

Infection Prevention and Control Programs were first introduced in the 1950s. Initially referred to as Infection Control Programs, these hospital-based programs focused on the control of hospital-acquired infections, which were referred to as nosocomial infections. As health care increased in complexity and sophistication and expanded beyond acute care, the mandate of IPCPs should have expanded to encompass infections in all settings across the health care continuum. Contrary to expectations, however, IPCPs have seen their resources either decrease or remain static, and consequently have failed to achieve the needs of the expanding mandate.

Health care associated infections contribute to significant morbidity, mortality, and economic costs^(9-12) and the risk of hospital acquired infections is increasing.^(13;14) These infections are the most common complication affecting hospitalized patients.⁽⁸⁾ Effective IPCPs reduce nosocomial infections by at least 30%⁽¹⁰⁾ and have repeatedly been shown to be effective in controlling infection outbreaks in the health care setting. Appropriate resources, both in quantity and in quality, are required to support effective IPCPs and contribute to the safety of Canadian patients.

3.0 Health care associated infections are an important problem

In 1985 there were an estimated 2.1 million nosocomial infections with 80,000 attributable deaths in the US.^(15;16) Health care associated infections were the fourth most common cause of death.⁽¹⁵⁾ Using this published data on the expected incidence of HAIs and the number of hospital discharges in Canada, Zoutman et al⁽¹⁷⁾ estimate that 220,000 nosocomial infections, which result in more than 8,000 deaths, occur in Canadian hospitals each year.

Health care associated infections are extremely costly. No data or published total costs are available in Canada; however, the estimated costs of MRSA alone are between $42 and $59 million per year for Canadian hospitals.⁽¹⁸⁾ In 2000, annual estimates of the total costs of HAIs in the US were $5 billion,⁽¹⁹⁾ and in the United Kingdom (UK) these costs exceeded £930 million (in 1994–1995).⁽¹²⁾ There is no reason to believe that the relative Canadian costs are any lower than those in the US or the UK. These estimates speak to direct costs and do not capture the huge indirect costs of HAIs.

3.1 Impacts of health care associated infections: an overview

Society as a whole suffers negative consequences from HAIs.^(9;12;20) These infections, including their investigation and treatment, have both immediate and future implications for the individual, the health care system, and the local, national and global communities. Although there are limited data describing the societal impact of HAIs,⁽²¹⁾ some emerging examples illustrate their breadth and gravity:

There is a need for antimicrobial therapy that has long-term worldwide effects on health.^(22-25)
Medical care contributes significantly to environmental pollution and consumption of limited natural resources.⁽³⁾
Many are concerned about safety in health care facilities. HAIs are a major contributor to significant adverse events in health care,^{(1;7;8;26-31)} affecting between 3.18% and 19.73% of Canadian hospital admissions.⁽³²⁾At least one-third of adverse events (including HAIs ) are considered to be preventable.^(10;28;29)
The SARS epidemic in Toronto and elsewhere took a significant toll on the health care system.
The impact of HIV and hepatitis C infections on the blood system is still being felt by the health care system.

The impact of HAIs on individuals is well documented:

increased morbidity and mortality^(4;9;33-37)
decreased well-being and increased suffering^(9;38)
psychosocial effects as a result of isolation,⁽³⁹⁾ particularly in long-term care facilities that are considered home for many individuals^(40-42)
safety issues including reduced attention to isolated patients from health care personnel⁽⁴³⁾ (the impact of isolation is an important consideration as recent Canadian data show that 92% of VRE patients were isolated and 22% of these patients were on isolation for more than 28 days)⁽⁴⁴⁾
prolonged length of stay in hospitals with subsequent increased direct costs and reduced bed availability (e.g., prolonged waiting time for patients needing joint replacements)

As with HAIs in general, there are significant impacts on patients that have acquired antimicrobial resistant organisms (AROs). These may include the less tangible effects on the individual such as threats to the person’s well-being and erosion of a sense of security.^(2;45) The person’s trust in the health care system diminishes and the perception of ill health increases in response to prolonged treatment time, social isolation, and time lost from work or family.^(2;22;46) The consequences associated with AROs will burden future generations as well as our own.⁽²²⁾

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3.2 Costs and rates of health care associated infections

The management of HAIs exacerbates rising health care costs, although the exact attributable cost to society is unknown.⁽²¹⁾ Related financial impacts of HAIs include an increased time away from home for the individual with an infection⁽²⁰⁾ and if employed, the individual experiences a loss of work and wages^(47;48) or at least an increased use of sick leave. The indirect costs, such as a family members’ time lost from work in caring for the affected individual, must be considered in addition to the direct costs of increased use of resources^{(12;21;47;49)} but have not been well quantified. Overall, HAIs have a detrimental effect on the individual’s quality of life^(38;47;48) and are very costly.

The HAI financial burden to the health care system has been estimated by measuring a number of indices including increased

number of readmissions to hospital^(4;9;20)
length of stay^{(9;18-20;33;34;49;50)}
use of antimicrobials^{(18;20;45;50;51)}
surveillance and isolation measures for AROs^(18;51-56)
laboratory^(18;50;51) and radiological services(20) attributable to diagnosing and managing HAIs
overall direct or indirect costs^{(4;9;19;20;33;35-37;49;57)}
cost attributable to outbreaks^(53;58)

Tables 1 to 4 summarize reports describing rates and financial burdens associated with HAIs across the continuum of care in several countries. Although acute care institutions are best studied, the allocation of an infection to a particular setting is increasingly arbitrary because the boundaries of the health care sectors have become blurred due to changes in the level of care being provided in different settings.(4) For example, there is an increasing amount of “acute care” (such as ventilator care) being provided in the home setting.

3.2.1 Acute care setting

The increased economic costs of HAIs are mainly a result of extra days the patient has to stay in hospital. Estimated increased length of stays published in the US in 2000 were 1–4 days extra stay for a urinary tract infection, 7–8 days for a surgical site infection, 7–21 days for a bloodstream infection, and 7–30 days for pneumonia. Costs of these infections vary from $600 for a urinary tract infection to over $50,000 for a bloodstream infection.⁽¹⁹⁾

**Table 1: Acute care HAI rates, attributable costs and increased length of stay**
Setting	P*	IR**	↑Costs	↑LOS***
Notes: * Infections/100 patients Infections/1,000 patient or device days * Length of stay in days
All health care associated infections
ICU ⁽⁵⁹⁾	21.6	20.3
ICU ⁽⁶⁰⁾	36.0
Gyn. & Ortho ⁽⁶¹⁾	5.9	6.3
NICU ⁽³⁴⁾	5.5		US$10,440	5.2
Hosp. wide ⁽⁶²⁾		5.7–6.9
Hosp. wide ⁽²¹⁾			US$13,973
Surgery ⁽⁶³⁾	15			10.6
Paediatrics ⁽⁶⁴⁾	7.7
Paediatrics ⁽⁶⁵⁾	5.7
Blood stream infection
Medicine ⁽⁶⁶⁾		1.22–1.36
ICU ⁽⁵⁹⁾	4.5	4.2
Gyn. & Ortho ⁽⁶¹⁾	0.12
Hosp. wide ⁽³⁶⁾			US$2,836 +
Hosp. wide ⁽⁶⁷⁾		0.7–1.1	US$4,420–$7,229
Hosp. wide ⁽²¹⁾			US$38,703
Central venous catheter blood stream infection
Hosp. wide ⁽⁶⁸⁾		8.9
ICU ⁽⁵⁹⁾	4.8	3.8
ICU ⁽⁶⁹⁾	1.0–4.7	1.6–7.6
Surgical Site Infection
Gyn.& Ortho ⁽⁶¹⁾	2.0
Surgery ⁽²⁰⁾	1.96		Can$3,937–$4,228	10.2
Surgery ⁽³³⁾			US$53,000	12
Urinary tract infection
ICU ⁽⁵⁹⁾	7.8	8.5
Gyn. & Ortho ⁽⁶¹⁾	3.3
Hosp. wide ⁽³⁶⁾			US$676	1–2
Pneumonia
Hosp. wide ⁽²¹⁾			US$17,677
Ventilator-associated pneumonia
ICU ⁽⁵⁹⁾	9.6	9.4
ICU ⁽⁷⁰⁾		19.5-21.7
Methicillin-resistant Staphylococcus aureus
Hosp. wide ⁽²¹⁾			US$35,367
Surgery ⁽⁷¹⁾	5.4
Orthopedic ⁽⁷¹⁾	1.4
Medicine ⁽⁶⁶⁾		1.93-2.19
Vancomycin-resistant enterococcus
Adult Oncology ⁽⁷²⁾		0.45-2.1 (BSI)

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3.2.2 Long-term care setting

The HAI rate in long-term care, estimated at 5–6/1,000 resident days, approximates the hospital HAI rate.⁽⁴¹⁾ Urinary tract infections are the most common HAI found in long-term care facilities.^(41;73;74) Wide variations in infection rates in long-term care are largely explained by the use of different definitions and case ascertainment methods^(4;75) as well as the variation in types of long-term care settings.^(74;75) Nonetheless, knowing the incidence of HAI in long-term care is particularly important in view of the increased morbidity, cost and negative impact on quality of life associated with these infections in the elderly population.⁽⁷⁴⁾ Along with emotional and psychological disruption, there are additional transportation and treatment costs should the long-term care resident need to be transferred to the acute care setting for treatment.

**Table 2: Long-term care facility health care associated infection rates, attributable costs and hospital stay**
ref #	IR*	↑ costs	↑ hospital LOS**
Notes: Infections/1,000 resident days * Length of stay in acute care hospital
All health care associated infections
⁽⁷⁵⁾	3.82
⁽⁴¹⁾			5.0–6.0
⁽⁷⁶⁾			2.0–6.7
Blood stream infection
⁽⁷⁵⁾	0.06
⁽⁷⁶⁾	0.02
Urinary tract infection
⁽⁷⁵⁾	1.51
⁽⁷⁶⁾	0.18
Respiratory infection
⁽⁷⁵⁾	1.15
⁽⁴⁾	0.7–4.4
Pneumonia
⁽⁷⁷⁾	0.27–2.5	US$10,000
Skin and soft tissue
⁽⁷⁵⁾	0.86
⁽⁴⁾	0.1–2.1
⁽⁷⁶⁾	0.55
Gastrointestinal infection
⁽⁷⁵⁾	0.27
⁽⁷⁶⁾	0.40
Vancomycin-resistant e nterococcus
⁽⁷⁸⁾		US$12,061

3.2.3 Ambulatory care setting

The costs of HAIs in non-hospital settings have not been estimated, at least partially because IPCPs, including their surveillance activities, are limited or absent in these settings.^(4;41;79-84) In one Canadian study, surgical site infection rates in the ambulatory setting were 1.4-3.1% after hernia repair.

3.2.4 Home care setting

Despite a dramatic increase in the number of patients receiving care in the home, with an estimated 10% of these patients requiring invasive medical devices for their care, the infection rate in the home care sector is not generally known.^(80;81) However, the Centers for Disease Control and Prevention, Atlanta,⁽¹⁹⁾ cites a recent study reporting an infection rate of 16% in a home care population of 5,148 patients, and suggests home care patients are at risk for the same infections seen in hospitals.⁽⁷⁹⁾

**Table 3. Home care health care associated infection rates by study**
Health care associated infection	Ref. #	I*	IR**
Notes: Infections/100 patients * Infections/1000 patient or device days
All
	⁽⁸⁵⁾	5.1%
Central venous catheter-blood stream infection
	⁽⁸⁶⁾		0.3–1.4
	⁽⁸⁷⁾		1.1
Catheter-associated urinary tract infection
	⁽⁸⁷⁾		4.5

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3.2.5 Antimicrobial resistant organisms

The emergence of AROs has compounded the impact of HAIs. The costs of antimicrobial resistance have been reported as crude estimates⁽⁸⁸⁾ based on the following indices^(2;45):

increased length of hospital stay
additional investigations required (e.g., laboratory and radiological)
additional drug treatment courses because, with AROs , the person is less likely to respond to the first antimicrobial used to treat the infection
increased costs for isolation procedures

Recent estimates, which are considered conservative, suggest that infections with AROs add between $39 and $52 million annually to the indirect and direct hospitalization costs of health care delivery in Canada.⁽⁴⁵⁾

4.0 Changes in Health Care and their Impact on Infection Prevention and Control Programs

Health care reform over the past decades has resulted in a health system that looks and operates differently from the system that evolved during the previous century.⁽⁸⁹⁾ Administrators and policy makers have been required to make health care reform decisions with little empirical evidence to guide the decision-making process.^(90-92) Other factors that have impacted changes include an aging and varied population, increasing complexity of patient conditions and clinical interventions, realignment of health care delivery including restructuring, and changes in health care funding. Each of these changes necessitates an expanding role^(17;93-95) for IPCPs in an era of emerging and re-emerging infectious diseases, global health concerns, and limited resources.

4.1 Health care needs of specific populations

Those at the extremes of age require specialized health care. At one end of the scale, premature infants have an improved survival rate with a corresponding increase in the cost of their care. At the opposite end of the scale, there are greater numbers of older, frail seniors and a substantial increase in the incidence and prevalence of chronic diseases such as cardio- and cerebrovascular diseases, diabetes, dementias, and end-stage renal disease.^(89;96) The treatment of these chronic health problems is increasingly successful, further prolonging life. In 1997–1998, patients over 65 years of age accounted for 52% of the hospital patient days, but represented only 12% of the population.⁽⁹⁶⁾ With an anticipated increase in the population of individuals older than 65 years of age over the next two or three decades, the allocation of health care dollars to the elderly population will continue to increase.

There are unique health care needs for specific populations such as children, First Nation’s peoples, immigrants and refugees, those living in rural or remote areas,⁽⁸⁹⁾the poor, and the homeless. There are implications for the prevention and control of infections for all of these groups. For example, the higher than national average rates for multi-drug resistant tuberculosis among the homeless population is well documented^(97-101) and outbreaks of this infection in correctional facilities have occurred.⁽¹⁰¹⁾

4.2 Increasing complexity of patients

Irrespective of patient age, since the late 1970s, there has been an increase in the acuity of illness in Canadian hospitals coupled with a decrease in the patient length of stay.^(13;96;102) The acute care hospital is not the only delivery site to experience an increase in patient acuity. Patients with multiple health problems and complex physical and psychosocial needs are increasingly being cared for in non-acute health care settings.^(81;90;103) Both the acuity and the number of patients in the home care^{(79;81;86;87)} setting have intensified and early discharge from acute care facilities challenges home care service providers and agencies.⁽¹⁰⁴⁾

4.3 Increasing complexity of treatment interventions

Today’s complex medical care requires multiple health care services and providers.⁽⁸⁹⁾ There has been an increase in the use of invasive medical devices such as tracheostomy tubes, respirators, feeding tubes, central venous catheters, medications delivered by daily injections, indwelling urinary catheters, and peritoneal dialysis catheters for the treatment of chronic renal failure.^(42;74;105) These are all now commonly used in ambulatory,^(82;106) long-term,^(42;103;107) and home care settings.^{(79;81;86;87;90;108)} Outpatient antibiotic therapy in the ambulatory care setting is well documented and shows positive economic and medical outcomes.^(109-113)

There have also been substantive changes in health care design. Advances in technology, including telehealth and telemedicine, allow health care practitioners to provide sophisticated preventive, diagnostic and treatment services at distant sites.⁽⁸⁹⁾ The impact of these novel delivery systems on HAIs is unknown.

4.4 Realignment of health care delivery across the continuum of care

Canadian Institute for Health Information (CIHI) data⁽⁹⁶⁾ demonstrate that the hospital discharge rate (i.e., a measure of inpatient hospital use) decreased by 14% between 1994 and 1998. During the same time, the average length of stay decreased from 7.4 to 7 days and there was a 15% decline in acute inpatient hospital surgeries, with a corresponding increase in outpatient surgery. A continued reduction in the number of hospital beds is expected in the current decade.⁽⁸²⁾

Canadian⁽¹⁰³⁾ and American analysts^(82;92) predict that the majority of medical care will move to the ambulatory care setting during this century. This includes an estimated 75%–80% of surgical procedures^(82;114) and oncology services⁽⁸²⁾ to be provided on an outpatient basis. The Centers for Disease Control and Prevention in Atlanta reports that the number of patients receiving care in their homes is increasing and notes that the amount spent on home health care in the United States rose from $2 billion in 1988 to an estimated $25 billion in 1999. Eight million Americans received medical care in their homes in 1996.⁽⁷⁹⁾ The Canadian Hospital Association^(89;103) describes the same general trends for Canada. Employment data from CIHI⁽¹¹⁵⁾and other sources⁽¹⁰²⁾ demonstrate a shift of registered nurse employees from acute care hospitals to community-based settings. Between 1994 and 1999 the percentage of RNs employed in hospitals decreased (66.4%–62.5%), but increased in community health agencies (6.0%–8.1%), nursing homes (10.8%–11.7), and home care (3.5%–4.0%).⁽¹¹⁶⁾

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4.5 Changes in health care funding

Three noteworthy trends in health care funding will affect all health programs. The first funding trend is seen in the proportion of spending among the health care sectors. Although current CIHI data show that hospital care is the leading category for health care spending,⁽¹¹⁷⁾ starting in the mid-1970s, the portion of the total Canadian health penditure designated for hospitals declined.^(102;117) The second trendis a steady—albeit gradual—shift in the ratio of public to private health care funding, with the proportion of public funding declining relative to private funding.⁽¹¹⁷⁾ The third trend, a lack of sustained health care funding,⁽⁸⁹⁾ is probably the most significant in terms of health program development.

4.6 Implications for Infection Prevention and Control Programs

Changes in requirements for health care have implications for IPCPs. An interaction between chronic diseases and the physiological changes associated with aging sets the stage for the development of infections in the elderly.⁽⁴²⁾Advanced age is associated with an increased risk of pneumonia because of decreased lung capacity and cough reflex, as well as increased co-morbidities.⁽⁷⁷⁾ The use of invasive devices such as tracheostomy tubes, respirators, feeding tubes, intravenous catheters, daily injections (e.g., insulin), indwelling urinary catheters, and peritoneal catheters for treatment of chronic diseases, along with the reduced mobility, bowel and bladder incontinence, and poor nutrition all compound the risk of infection.^(42;74) Living in an institutional environment further increases the older person’s risk for acquiring infection.^(24;74)

Increased acuity of home care patients combined with the use of invasive devices necessary for home health treatment increases the patient’s risk of infection.⁽⁷⁹⁾ Although a lack of epidemiological data and under-reporting of infections in the home health care environment is acknowledged,^{(4;24;81;83;118;119)} outbreaks including bloodstream^(86;120) and catheter-related genitourinary infections,⁽⁸⁴⁾ including candidemia,⁽¹²¹⁾ have been reported among home care patients. Home care nurses have always faced a significant challenge in adapting acute care infection prevention and control strategies to the home care setting.⁽¹²²⁾

In the past, the risk for infection in ambulatory care settings was considered to be low. Currently, with the varied patient mix (from well to acutely ill) and invasive procedures, risk management of infections in this population is increasingly complex. Three areas in ambulatory care are particularly important from an infection prevention and control perspective: the ambulatory surgical setting, the ambulatory infusion setting, and the dialysis centre setting.⁽⁴⁾ Herwaldt et al.⁽⁸²⁾ list risk factors in the ambulatory care setting that include the following:

greater potential for unsafe handling and disposal of infectious wastes
inadequate ventilation, e.g., recirculation of unfiltered air, no negative pressure rooms
inadequate cohorting of patients (one entrance, one waiting room)
staff members’ inadequate knowledge of infection control due to high staff turnover and the lack of dedicated education programs
inappropriate disinfection practices for equipment
inappropriate use of flash sterilization
inadequate space to allow for separation of clean and dirty activities

Realignment of health care delivery within the institution frequently necessitates construction and renovation projects. These have resulted in documented outbreaks related to Legionnaires’ disease^(82;123) and Aspergillus species infections.⁽¹²³⁾ Infection prevention and control involvement during renovation and construction is necessary to prevent outbreaks related to such projects.^(124-127) Both Health Canada (2001)⁽¹²³⁾ and the Canadian Standards Association (2003)⁽¹²⁸⁾have published infection control recommendations for construction and renovation in a health care facility.

Restructuring of health care has been reported to contribute to an increased risk of HAIs^{(123;124;126;129)} and to the transmission of AROs.⁽¹³⁾ University of Alberta Hospital⁽¹³⁰⁾ investigators reported that changes in the health care system impacted their hospital’s nosocomial infection rates. There were significant reductions in the number of hospital beds (↓ 10%), annual admissions (↓ 19%), and patient days (↓ 17%) between 1993–1994 and 1996–1997. During the same period there was a 31% increase in the number of and a 60% increase in the rate of blood stream infections.

Understaffing,^(131-134) a decrease in the level and skill of health care providers,⁽¹³⁵⁾ understaffing and overcrowding⁽¹³⁶⁾ and lack of infection prevention and control education⁽¹³⁾ are associated with the transmission of micro-organisms and the development of HAIs. It is important to note that a deterioration in the quality and outcomes of patient care has been reported.^{(26;91;137-139)}

In the past decade, surveillance, prevention, and control of AROs have become a major component of IPCPs.^{(17;51;93;140)} Antimicrobial resistance involves the emergence of drug-resistant bacteria, parasites, viruses and fungi.⁽¹⁴¹⁾ The increasing prevalence,⁽⁴⁶⁾ the rapid emergence of new AROs,⁽¹⁴⁰⁾ and multi-drug resistance of many of these organisms⁽¹⁴²⁾ compound the resistance problem. Antimicrobial agents available to the practitioner for the management of infections with AROs are limited or, in some cases, non-existent.^(46;141-143) Coexistent with this has been a decrease in the development of new antimicrobials.^(22;142) Antimicrobial resistant organisms such as MRSA and VREhave been reported to lead to increased length of hospitalization, increased morbidity, and increased costs.⁽¹⁴⁴⁾

Antimicrobial resistance, once seen primarily in intensive care unit settings, is now a problem throughout the acute care hospital⁽¹⁴²⁾ and in long-term care settings.^{(73;105;145-147)} One American study reported MRSA colonization rates of up to 53% in the residents of some long-term care facilities.⁽¹⁴⁰⁾ Partly because of increasing patient movement between health care sectors (e.g., patients receive dialysis or chemotherapy in both the inpatient and outpatient settings),⁽¹⁴⁰⁾ AROs have been identified in all health care settings^(46;142;148) as well as in the community.^(149-153)

There is evidence to show that, along with the development of de novo community strains,⁽¹⁵⁴⁾ hospital-acquired strains of MRSA are being transmitted into the community.⁽¹⁴⁹⁾ Overcrowded living conditions, such as those still found in many First Nations and Inuit communities, are strongly implicated in the spread of community pathogens⁽¹⁵⁵⁾ including AROs.⁽¹⁴⁹⁾ According to data from the Canadian Nosocomial Infection Surveillance Program, there has been a continued increase of MRSA colonization rates and infections in Canadian hospitals. For further information, please refer to the following website: http://www.phac-aspc.gc.ca/nois-sinp/projects/index-eng.php. This poses a risk to patients and is a potential financial burden affecting health care resources. The Canadian Nosocomial Infection Surveillance Programs and others^(93;156-158) recommend that IPCPs perform active surveillance to identify patients with AROs and implement other preventative measures to control their cross transmission.

Emergence or re-emergence of community-acquired, communicable diseases [(e.g., invasive group A streptococcal disease,⁽¹⁵⁹⁾ community-acquired MRSA, multi-drug-resistant tuberculosis,^(160;161) and C. difficile,^(14;162)), food- and water-borne infections (e.g., E. coli 0157:H7), zoonoses (e.g., Salmonella⁽¹⁶³⁾), plague,⁽¹⁶⁴⁾ AROs,^{(42;142;165-168)}] increased international air travel,⁽¹⁴¹⁾ and potential bioterrorism⁽¹⁶⁹⁾ all provide an opportunity for the development and transmission of infections.^(40;72;170) This is of concern not only within Canadian health care settings, but also throughout the world.^(23;171) These concerns all point to an urgent need to expand IPCPs.

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4.7 Limited resources for Infection Prevention and Control Programs

Changes in the health care system have expanded the range of IPCP activities.^(93;95;172) These changes necessitate an increase in infection prevention and control resources in order to be effective in the current health care system and to maintain the essential IPCP components for acute care facilities that Haley⁽¹⁰⁾ identified almost three decades ago.

The emergence of new infectious diseases such as SARS has emphasized the need for surge capacity in infection prevention and control as well as in other health care services. The concept of surge capacity is based on sufficient capacity or appropriate resources for day-to-day operation and an ability to redirect resources in a time of need.⁽¹⁷³⁾ Despite the need for more resources for effective infection prevention and control, and the need for a surgecapacity for these programs, a survey conducted by the Association for Professionals in Infection Control and Epidemiology in the United States comparing data from 1994 and 1997 found that IPCP human resources had actually decreased.^(95;174) The study cites the following examples:

Seventy-six per cent of practitioners surveyed reported that their workload had increased.
The number of locations where infection prevention and control practitioners must cover increased 63%.
Forty-five per cent of infection prevention and control practitioners had additional jobs beyond infection control responsibilities.
Infection control staffing levels decreased or remained the same for 83% of respondents.
Eighty-three per cent of respondents said that funding for infection prevention and control had decreased or remained the same, despite increased workloads.

A recent report incorporating 20 years of data revealed a 145% increase in infection control activities whereas resources for IPCPs lagged far behind.⁽¹⁷⁵⁾ Inadequate staffing was cited as the most common reason for non-performance of essential infection prevention and control responsibilities. Competing infection prevention and control responsibilities had a negative influence on time available to perform surveillance,⁽⁹⁴⁾even though surveillance is known to be an essential component of an effective IPCP.^(10;176-178) In a 2003 survey of Canadian IPCPs, 23% of hospitals that responded were conducting fewer than half the recommended surveillance activities.⁽¹⁷⁾ Other Canadian IPCPs have reported that surveillance activity is primarily related to AROs,^(179;180) at the expense of other HAIs.^(179;180) Yet, Canadian hospitals that perform aggressive surveillance for HAIs demonstrate fewer of these infections.⁽¹⁸¹⁾

A review to assess the human resources available to IPCPs in Ontario hospitals was conducted in 1999. Results of a survey mailed to all acute-care hospitals in Ontario concluded that infection control practitioner time in Ontario hospitals is well below the 1985 recommendation of one full time equivalent position per 250 beds.⁽¹⁷⁹⁾ This ratio was derived before the emergence of AROs, bioterrorism, emerging infections, patient safety issues, and infection prevention and control job responsibilities broadening across the continuum of care.^(95;172) The authors noted that infection control practitioners in Ontario spent approximately 20% of their time on surveillance, prevention and control of antimicrobial resistant organisms, further reducing program resources within that province.⁽¹⁷⁹⁾ A later Canadian study⁽¹⁸¹⁾showed that investments in surveillance significantly reduced antimicrobial resistant organism rates.

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