Healthcare Infection Prevention-Managing Critical Data and Information, Including Surveillance for Infections

Recommendation 1: Infection control personnel should develop policies and procedures for ongoing communication with other health care organizations (HCOs) to identify, prevent, manage, and control infections as patients move between HCOs throughout the continuum of care. Category II

• Report infectious complications and adverse events associated with medical and surgical procedures (i.e., surgical site infections) to the HCO in which the procedure was performed or from which the patient was discharged.

• Report epidemiologically important infections to the HCO to which the patient will be transferred.

Recommendation 2: Surveillance of health care associated infections must be performed. Category I

Incorporate the following elements in the surveillance process:

• Identification and description of the problem or event to be studied;

• Standard case definitions appropriate for the setting;

• Definition of the population at risk;

• Selection of the appropriate methods of measurement, including statistical tools and risk stratification;

• Identification and description of data sources and data collection;

• Definition of numerators and denominators;

• Preparation and distribution of reports to appropriate groups.

Recommendation 3: Surveillance data must be appropriately analyzed and used to monitor and improve infection control and health care outcomes. Category I

Recommendation 4: Clinical performance and assessment indicators used to support external comparative measurements should meet the criteria previously delineated by APIC and SHEA for hospitalized patients. Category II

Specifically, these indicators and their analyses must address:

• How process is related to outcomes;

• How to measure variation and quality;

• That the numerators and denominators are defined;

• That data collection is feasible, and the collected data are collected completely and reliably;

• That the data are appropriately risk-adjusted when analyzed;

• That data be adjusted for the populations' severity of illness and case-mix differences when analyzed before external comparison;

• That personnel be trained regarding proper study and use of indicators;

• That benchmarks be developed and used to compare the indicators' performance.

Developing and Recommending Policies and Procedures

Recommendation 5: Written infection prevention and control policies and procedures must be established, implemented, maintained, and updated periodically. Both Categories II and III

• The policies and procedures should be scientifically sound.

• The policies and procedures should lead to improved prevention of infections and other adverse events or improved patient and employee outcomes.

• The policies and procedures should be reviewed regularly to assess their practicality and cost-effectiveness.

• The policies and procedures should incorporate compliance with regulatory issues.

Recommendation 6: Policies and procedures should be monitored periodically for effectiveness, both to ensure that staff are able to comply fully with and fulfill organizational requirements and to ensure that the policies are having the desired result in preventing and controlling infections. Both Categories II and III

Compliance With Regulations, Guidelines, and Accreditation Requirements

Recommendation 7: HCOs should engage infection control personnel in maintaining compliance with relevant regulatory and accreditation requirements. Both Categories II and III

Recommendation 8: Infection control personnel should have appropriate access to medical or other relevant records, information in regard to the HCO's compliance with regulations, standards, etc., and to staff members who can provide information on the adequacy of the HCO's compliance with regard to regulations, standards, and guidelines. Both Categories II and III

Recommendation 9: The infection control program should collaborate with, and provide liaison to, appropriate local and state health departments for reporting of communicable diseases and related conditions and to assist with control of infectious diseases in the community. Both Categories II and III

Employee Health

Recommendation 10: The infection control program personnel should work collaboratively with the HCO's employee health program personnel. Category II

• The HCO should have access to consultation and direction from a physician (or designee) with expertise in infectious disease and health care epidemiology.

• Infection control personnel should review and approve all employee health policies and procedures that relate to the transmission of communicable diseases in the HCO.

Recommendation 11: At the time of employment, all HCO personnel should be evaluated for conditions relating to communicable diseases. Both Categories II and III

The employment record should include the following:

• Medical history, including immunization status and assessment for conditions that may predispose personnel to acquiring or transmitting communicable diseases;

• Tuberculosis screening;

• Serologic screening for vaccine-preventable diseases, as deemed appropriate;

• Such medical examinations as are indicated by the above.

Recommendation 12: The HCO evaluates employees and other health care workers (e.g., students, volunteers) for conditions related to infectious diseases that may have an impact on patient care, the employee, or other health care workers periodically. This evaluation should include a review of required immunizations and status of tuberculosis screening. Both Categories II and III

• Medical records of all health care workers must be kept confidential.

• The HCO should track employee immunization and tuberculosis screening status.

Recommendation 13: Employees must be offered immunizations based on regulatory requirements. HICPAC Personnel Guidelines and recommendations of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices for health care workers should also be followed. Both Categories I and III

Recommendation 14: The HCO's employee health program should institute policies and procedures for the evaluation of exposed or infected health care workers. Category I

• Exposed health care workers should be evaluated for circumstances surrounding the exposure, evaluation of symptoms, need for postexposure prophylaxis, need for treatment, and work restrictions.

• Infected symptomatic and asymptomatic health care workers should be assessed for disease communicability, work restrictions, and treatment, as appropriate.

Intervening Directly to Prevent Infections

Recommendation 15: Infection control personnel in HCOs must have the capacity to identify and implement measures to control endemic and epidemic infections and adverse events. Category I

• HCOs must have an ongoing system to obtain pertinent microbiologic data.

• Ongoing communication and consultation with clinical staff throughout the organization must be maintained to identify infectious and adverse events, to assist in maintenance and monitoring of infection control procedures, and to provide consultation.

• When an outbreak occurs, infection control personnel must have adequate resources and authority to ensure a comprehensive and timely investigation and the implementation of appropriate control measures.

• Institutional policies and procedures should be developed so that roles and responsibilities are outlined clearly.

Educating and Training Health Care Workers, Patients, and Nonmedical Caregivers

Recommendation 16: HCOs must provide ongoing educational programs in infection prevention and control to health care workers. Both Categories I and III

• Infection control personnel knowledgeable regarding epidemiology and infectious diseases should be active participants in the planning and implementation of the educational programs.

Recommendation 17: Educational programs should be evaluated periodically for effectiveness. Both Categories II and III

• Educational programs should meet the needs of the group or department for which they are given and must provide learning experiences for persons with a wide range of educational backgrounds and work responsibilities.

• Participation of health care workers at educational programs should be documented.

Recommendation 18: The health care organization must have a mechanism to ensure that patients and caregivers receive appropriate information regarding infection prevention and control. Category II


Recommendation 19: The HCO must assure adequate personnel and supporting resources to fulfill the functions of the infection control program. Category II

Recommendation 20: All HCOs should have access to the ongoing services of a person who is trained in infection prevention and control (i.e., an infection control professional [ICP], who provides oversight for the infection control program). Category II

Recommendation 21: All HCOs should have access to continuing services of a physician trained in health care epidemiology. Category II

Recommendation 22: ICPs should be encouraged to obtain Certification in Infection Control. Category II

Other Resources

Recommendation 23: Resources should be provided for continuing professional education of employees and infection control personnel who work directly for the organization. Category II


1. Friedman C, Barnett M, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-of-hospital settings: A consensus panel report. Infect Control Hosp Epidemiol 1999; 20:695-705.