Infection guidelines reach beyond hospital

Panel suggests getting outside help

In what may signal a landmark expansion of infection control beyond the hospital, a consensus panel has issued a report on the essential infection control requirements for out-of-hospital settings.

With representation from infection control professionals, epidemiologists, public health officials, and quality accreditation experts, the panel has established the first consensus program standards in a rapidly expanding area of health care. The report calls for nonhospital settings to seek the oversight of hospital-based infection control professionals (ICPs) or infection control consultants in implementing the recommendations. (See recommendations, inserted in this issue.)

The panel concedes that some organizations will not be of the size or complexity to justify the resource commitment of a full-time, on-site ICP. However, the report emphasizes that an ICP should be consulted for oversight if the person charged with the responsibility for infection control in the health care organization is not specially trained or experienced in epidemiology.

"There may be a person designated, but the organization should still seek the wisdom and knowledge and experience of someone who is really trained in infection control and hospital epidemiology," says panel member Candace Friedman, MT (ASCP), MPH, CIC, manager of infection control and epidemiology at the University of Michigan Hospitals and Health Centers in Ann Arbor.

Moreover, given the increasing emphasis on cost containment and the need to justify expenditures, a trained and experienced ICP can be especially helpful in evaluating the benefits and requirements of the infection control program as outlined in the recommendations, the panel noted.

The panel was formed by the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America. It also included representation from the Centers for Disease Control and Prevention and the Joint Commission on Accreditation of Healthcare Organizations.

"It is the duty and responsibility of health care organizations to implement these recommendations," emphasizes William Scheckler, MD, hospital epidemiologist at St. Marys Medical Center in Madison, WI, in a written introduction to the report.1

ICP can evaluate recommendations

A key panel member in a similar consensus effort for acute care hospitals, Scheckler says the time has come to underscore the importance of infection control across the continuum.2

"Health care is no longer limited to the acute care hospital. It is a continuum from the home to the outpatient clinic, to the hospital, to nursing homes, to rehab facilities and [other] freestanding facilities," he says. "For example, at least 50% of surgical procedures that used to be done in the hospital operating suite are now being done in day-care surgical centers and surgeon’s offices. We felt it was important to examine what modest amount of literature was available for these sites and extend the good principles and practices for both epidemiology and infection control to these sites."

Indeed, the report notes that the last decade has seen much nationwide growth in managed care organizations, which has changed provider reimbursements and restructured the entire health care system.

As a result, diversification and integration strategies have blurred historical separations between hospitals, nursing homes, ambulatory care, physicians, and other providers. Accordingly, the degree and complexity of care provided in out-of-hospital settings has increased markedly in recent years.

"Infection prevention and control issues are important throughout this continuum of care," the consensus panel concluded. "Infections in patients may lead to serious morbidity and mortality, readmission or admission to a hospital, increased use of antibiotics, and increased costs of care. Performing surgical procedures, invasive device insertions, and managing and providing care for patients who are increasingly immunocompromised in these settings present new infection control challenges.

"Therefore, infection control practices must now encompass infections that patients may acquire as a result of their care or treatment outside the acute care hospital, as well as protect health care pro-viders and caregivers in these settings."

But the question inevitability arises about funding the recommendations, which call for surveillance, reporting, and interventions to prevent infectious complications in nonhospital settings. The consensus panel emphasized that health care organizations should provide the necessary resources and personnel to enact the recommendations.

"I think the resources will be there because the accreditation bodies are already looking at outpatient and other kinds of facilities, both at the state level, the Joint Commission level, and even the National Commission on Quality Assurance," Scheckler says. "All of these [groups] will recognize soon, if they haven’t already, that prevention of infections — protection of the patient and the health care worker — is in everyone’s best interest. So the resources will be there."

Panel discussions in forming the guidelines acknowledged that the level of response to the recommendations may vary considerably in different nonhospital settings, adds Friedman. "But part of what the document hopes to achieve is to help convince an organization that it really should support this kind of a program," she says. "I don’t see it as a wish list."

In implementing the recommendations, nonhospital settings should focus on their best assessment of their high-risk areas, she says. "Those are the areas that should be followed in some manner. I don’t think anyone on the consensus panel thought that surveillance in a home care setting would be identical to the type of surveillance in an acute care setting. It’s not that they need to do the same kinds of things. It’s that they need to evaluate what are their issues and then figure out the best way to [address them]."

Regardless of setting, ongoing communication across the continuum is one of the key recommendations to prevent infections as patients move to various points in the delivery system, she says.


1. Friedman C, Barnette 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.

2. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Infect Control Hosp Epidemiol 1999; 19:114-126.