CDC expands infection control programs across continuum of care

ICPs seen as valued customers’ in a changing health care market

In a move that should provide long-awaited support and guidance for ICPs in a changing health care system, the Centers for Disease Control and Prevention is dramatically expanding its infection control programs across the continuum of care, Hospital Infection Control has learned.

Changes include an expansion of traditional duties as well as new areas of emphasis for both the CDC hospital infections program and its advisory panel of clinicians, the Hospital Infection Control Practices Advisory Committee (HICPAC). It was clear from discussions at a Nov. 16-17, 1998 HICPAC meeting at the CDC in Atlanta that the litmus test for all future efforts will come down to one key word: prevention.

"My own very strong personal vision is that is ultimately what we are here for. Prevention really is the primary mission of all of our government activities," said Julie Gerberding, MD, MPH, director of the CDC hospital infections program. "Our big job is to protect patients, protect health care workers, and improve health care outcomes. It’s not anything new, but something that is really an expansion of our program and the priorities."

Aimed at keeping the CDC abreast of ongoing changes in health care delivery, the plans also call for the agency to expand beyond a strict focus on nosocomial infections to include other adverse outcomes and peripheral issues of increasing importance such as emerging infections, bioterrorism, and latex allergies in health care workers.

The changes were requested formally earlier last year in correspondence from HICPAC to U.S. Secretary of Health Donna Shalala. Discussions at the HICPAC meeting indicated that Shalala instructed CDC leadership to respond to the request, which was essentially granted in a CDC letter of reply that agreed with the need for the changes for both the hospital infections program and HICPAC. As a result, the HICPAC charter — which has limited the committee to developing infection control guidelines for acute care settings — is being revised to reflect a broader mission.

"This represents a major change in the focus of HICPAC . . . which I think is totally appropriate," said committee chairperson Elaine Larson, RN, PhD, FAAN, CIC professor of pharmaceutical and therapeutic research at Columbia University School of Nursing.

Though still subject to revision, a draft of the new HICPAC mission statement developed at the meeting stated the committee will "promote the well being of patients and of all members of the health care delivery team by providing evidence-based guidance and advocacy to the health care community and the Department of Health and Human Services for the prevention and control of infections and related adverse events." The scope includes, but is not limited to:

• traditional nosocomial infections;

• related events occurring in hospitals (e.g., latex allergy);

• infections and adverse events occurring in home care, long-term care facilities, dialysis centers, ambulatory surgical centers, rehabilitation facilities, and other out-of-hospital venues in which health care is delivered;

• [and] sentinel or emerging infectious threats, including bioterrorism evolving in the U.S. and abroad which would have significant impact on infection prevention and control and patient outcomes."

Changes should help ICPs

The expanded mission comes at a time when ICPs are already undergoing something of a professional self-assessment, struggling to preserve traditional roles while looking for opportunities to bolster their perceived value in a changing health care system. (See Hospital Infection Control, December 1998, pp. 186-187.) The revised CDC and HICPAC mission ultimately should help ICPs, particularly those who already have seen their programs expand beyond the hospital setting to affiliated offices and clinics, says Audrey Adams, RN, MPH, CIC, HICPAC member and infection control manager at Montefiore Medical Center in New York City.

"I have very positive feelings about the changes," she tells HIC. "[We] are moving with the changes in the health care system. At previous meetings we have discussed the need for us to expand our role. Infection control practitioners in the hospital setting are also expanding their roles."

For example, Adams has expanded her infection control program to 31 ambulatory care sites at Montefiore. Such horizontal program expansion justifies keeping infection control departments fully staffed at a time when inpatient census is decreasing, she notes.

"Although we know the acute care setting is still a major emphasis for us, we also have to be innovative in expanding our roles to all of the other health care systems," she says.

In that regard, it was announced at the meeting that the CDC and APIC are collaborating on a new research initiative that will address issues of infection control staffing. The traditional ratio of one ICP per 250 beds has long been considered outmoded, but the issue has not been formally studied under current care delivery conditions. The Association for Professionals in Infection Control and Epidemiology has funded a research fellow to work at the CDC for two years to address the issue, Gerberding said.

"Surveillance is the most important thing," he tells HIC. "You can’t take action if you don’t know what you are up against." "Hopefully that will help move us away from this relatively static concept of one practitioner per 250 beds," she said.

In addition, Gerberding outlined an ambitious agenda for change at the CDC hospital infections program that complements the revamped mission of HICPAC. The changes will include both a broader mission statement and a revised program title, probably within the next year, she told the committee.

"Clearly we have a lot of work to do within the non-acute care venues — everybody knows this," she said. "Probably the biggest dilemma that I’m facing is how to accomplish this incredible expansion of activities and programs of surveillance and research into these areas with no commensurate expansion in resources to do it."

While efforts are under way to increase funding and seek out supportive partnerships, "realistically" the CDC must now look to pare down or discontinue program efforts that no longer "meet the overall mission," she said. While discussions are under way within the CDC to identify those areas, Gerberding also spoke of preserving and strengthening "core competencies" such as the National Nosocomial Infections Surveillance (NNIS) system of sentinel hospitals; nosocomial outbreak investigations; health care infection control consultation, training, and education; and guidelines for both patient infection prevention and health care worker protection.

Concerning the latter, HICPAC has updated a series of infection control guidelines — including those for nosocomial pneumonia, patient isolation, and personnel health — since it was founded in 1991. Rather than continue such efforts independently, however, the CDC and HICPAC will now pursue more collaborative development of guidelines with professional organizations such as APIC and the Society for Health Care Epidemiology of America. Committee discussions underscored that such collaborations may help avoid duplication and maximize limited resources as efforts to move beyond the hospital setting are undertaken.

Gerberding described the new vision for the program in the nomenclature of business, raising an eyebrow or two on the committee when she dropped the traditional clinical terms in favor of a discussion of "customers" and infection prevention "products."

The customer base includes the traditional groups of ICPs, health care epidemiologists, and laboratorians, but now also targets health care administrators, chief executive officers, and financial managers. To improve customer service, the CDC hospital infections program will create a "help desk" to field inquiries and document its responses to better define the mission of the program based on its customers’ needs, she explained.

"Clearly our front-line clinicians, infection control practitioners, and health care epidemiologists are our No. 1 customer group," Gerberding said. "These people are the individuals who will have a direct impact on prevention. . . . The other customers are of increasing importance as well."

Regardless, any recommended interventions now must be undertaken with a broader view of the health care delivery system, she added.

"What we are really interested in now are infections both acquired and transmitted in health care delivery systems among both patients and their health care providers," she said. ". . . We do need to define target patients, but more than that we need to start to think about target populations. As the delivery system has expanded and patients are so mobile — moving from one center to another — the walls have come down. It is really not possible to think about constructing interventions in one compartment of that system without including those areas where that same patient will have been over time."

The target populations reflect some of those described in the CDC update of its emerging infections plan, including organ transplant and dialysis patients, and those who are elderly and immunosuppresed.1 Those groups represent vulnerable patients who are either at special risk for primary infections or at a high risk for having other negative outcomes, she noted. Diabetics, for example, are a patient population that remains at risk for adverse outcomes across the care continuum. Prevention efforts in the public health sector through immunizations and other interventions can offset some of the problems encountered by those patients in other settings, she said.

"This is a group of patients who throughout the entire spectrum of care are at high risk of all kinds of bad outcomes related to health status. Among them certainly are infectious diseases," Gerberding said. "They have a great deal of exposure to antibiotics. They need immunizations and vaccines to prevent some of these infections."

Likewise, accumulating evidence suggests dialysis patients are at particular risk for the emergence of staphylococcus strains resistant to vancomycin, said Gerberding, adding that developing strategies to reduce vancomycin use in that group is a high priority. In addition to such patient populations, the CDC program can serve as a vital link between health care settings and public health departments, she added.

"We are really strategically positioned in a wonderful situation because we are right at the interface between the traditional public health system on the one hand and the health care delivery system on the other," Gerberding told the committee. ". . . The more we look at public health departments, the more we can really emphasize that infections in the health care delivery system are really public health problems."

The key to expanding infection control efforts across the health care delivery system will be effective surveillance and communication, noted HICPAC member Ramon Monocado, MD, infectious disease specialist at Coronado Physicians Medical Center in San Diego.

Monocado was enthusiastic about the expanded mission for both HICPAC and CDC, particularly because the changes may translate to improved surveillance for all settings in the health care delivery system.

"Surveillance is the most important thing," he tells HIC. "You can’t take action if you don’t know what you are up against."