PRACTICE
FORUM
Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Mary Castle White, RN, MPH, PhD, 155 Marston Ave., San Francisco, CA 94112.
Infection control A new perspective
in public
health:
Dianna C. Hayden, RN, BSN Paducah,
Kentucky
The mission of the Public Health Service is to protect and advance the health of the American people by preventing and controlling disease.’ To fulfill this mission, public health personnel must employ the principles of infection control to deliver services in the safest, most efficient manner. Hospital infection control programs help to provide high levels of patient care through the surveillance, prevention, and control of nosocomial infections.’ They are ineffective, however, as models for public health because they are conducted in settings in which the environment, patient population, and staff are well defined. The environments of community settings are varied and patient populations are fluid. Therefore public health staff members must develop new and innovative programs to achieve the goals of surveillance and of prevention and control of nosocomial infections. The purpose of this article is to describe the Purchase District Health Department’s infection control program, which enables it to deliver services in a safe, efficient manner. BACKGROUND
The Purchase District Health Department serves western Kentucky, which includes eight rural counties that cover 2399 square miles From
the Purchase
Reprint 42066.
requests:
17/1113442
District Dianna
Health Hayden,
Department. RN, Route
2, Mayfield,
KY
with a population of 174,400.3* 4 There are six local hospitals, of which two are regional medical centers. The Health Department itself consists of nine clinical centers, four home health branches, one center for handicapped services, and two administrative offices. During the development of our infection control plan, the organization of the health department had to be carefully considered. Each center within the health department has administrative, nursing, clerical, and environmental service personnel. One organizational problem identified was that of implementing policies in 10 different sites with only one half-time nursing position designated to the program. PROGRAM
DEVELOPMENT
An effective infection control program must include (1) goals and objectives with a timetable to accomplish them, (2) policies and procedures that encompass all aspects of services, (3) in-service programs and implementation of these policies, and (4) an ongoing system for surveillance. Twenty-eight areas related to infection control were identified as being in need of policies. The areas of employee health, basic laboratory procedures, and instrument cleaning/sterilization are briefly discussed here. Employee health. The goal of our employee health program was to use the same concepts of preventive health offered the community while continuing to assess new risks encoun47
American
48
Hayden
INFECTION
tered in the workplace. An initial health history was administered to all employees to determine baseline health data. Laboratory procedures. Because the Health Department has only one comprehensive laboratory, center nurses must collect and prepare body specimens for tests performed on site or transport them to outside laboratories. Safe and uniform laboratory practices had to be developed. Instrument cleaning and sterilization. Characteristically our centers do not have the support services available to hospitals. Sterile and central supply services do not exist as units in our centers; therefore personnel had to be educated in these duties. Comprehensive procedures were needed for the maintenance of a sanitary environment and for the provision of disinfection and the storage of equipment.
IN=SERVICE PROGRAM8 IMPLEMENTATION
AND
An educational program was developed that involved an initial district-wide 2-day inservice workshop. Nurses and nursing personnel, who have the greatest physical contact with patients, also are at greatest risk of transmission of organisms.’ Infection control information is disseminated to the nursing supervisors to ensure a better understanding of the concepts, thus encouraging the supervisors to become advocates for infection control within the centers. Ongoing training ensures that employees will participate in at ‘least one in-service program yearly. The infection control practitioner (ICP) continues to be available for ongoing consultation and for occasions when an incident or a question arises. SURVEILLANCE
AND
REVISION
Wenzel states that “surveillance should ideally provide systematic and continuous observations . . . for the purpose of prevention and control.“5 Because of the geographic location of the health centers, it is not feasible for the ICP to make surveillance visits on a daily or even a weekly basis. Therefore a tool was developed that focused on aspects of infection prevention: in the sanitation of the environment, in the
Journal
of
CONTROL
practice of nursing and laboratory procedures, and in the delivery of environmental services. This enabled the administrator and supervisors to evaluate their health centers from an infection control viewpoint. The initial surveillance visit provided consultation with the ICP, initiated use of the surveillance tool, and evaluated the employees’ immunization status. The administrator and supervisors walked with the ICP throughout the facility, using the surveillance tool as a point of reference. Some of the deficiencies discussed, for example, were inconvenient placement and overfilling of containers for sharps and improper janitorial cleaning and storage. Suggestions to correct these deficiencies included obtaining varying sizes of containers for sharps for the clinic, the laboratory, and the home health settings, storing janitorial chemicals away from public access, and planning a structured schedule for correction, with measurable goals and a timetable for effecting the correction. Employees of the health centers were interviewed individually to establish baseline immunization information on tetanus, measles, rubella, and hepatitis B. The only mandatory screening was a yearly tuberculosis skin test. Employees whose immunizations were not up to date were encouraged to be immunized. These interviews resulted in an increase in the number of protected employees. Thirty-eight tetanus boosters were given, which increased employee protection to 80%. Fifty-five employees are completing hepatitis vaccination, resulting in the protection of 65% of the nursing staff. Measles immunity was identified at 90% either by vaccine, disease, or age. Nine persons were given measles-mumps-rubella vaccine, which brought rubella immunity to 68%. All information from the health history data was entered into the computer, which permits evaluation of the status of immunity of all employees in the event of a communicable disease outbreak or employee incident. ROLE OF THE PRACTITIONER
INFECTION
CONTROL
The role of the ICP includes activities such as collection and analysis of data; planning, implementing, and evaluating infection control
Volume February
18 Number
1
Infection control in public health
1990
measures; education and prevention; development and revision of policy; and consultation and management .6 The ICP in our program is a public health nurse with a basic knowledge of community health and the needs of health centers. She prepared for the ICP role by attending courses on infection control and epidemiology response to communicable outbreaks in the community. It is the goal of the department that as the program develops the ICP’s role will more effectively reflect that described by Pugliese et a1.6 SUMMARY
As public health continues to meet the challenges of old and new health risks, the practice of infection control will be an integral part of its services. The public health infection control program should include effective policies and procedures, in-service programs and implementation, and systems of surveillance specific to each department. Public health personnel must place emphasis on the practice of infection
49
control in the community setting. The ICP who accepts this challenge will be in the forefront of infection control in public health. Infection control is a respected part of the hospital setting and now is the time for the ICP to tailor this program to the public health delivery system.
References RE. PHS commitment to combating HIV in1. Windom fection and AIDS. Public Health Rep 1988;103(suppl l):l-2. 2. Axnick JK, Yarbrough M. Infection control: an integrated approach. St. Louis: CV Mosby, 1984: 1. 3. U.S. Department of Commerce. 1980 census of population: number of inhabitants (Report No. PC80-l-A19). Washington, D.C.: Bureau of the Census, 1982. of Commerce. Kentucky economic sta4. U.S. Department tistics. Washington, D.C.: Bureau of the Census, August 1987. 5. Wenzel RP. Prevention and control of nosocomial infections. Baltimore: Williams & Wilkins, 1987:57,71. 6. Pugliese G, Larson E, Foote SB, Jackson MM, Hierholzer WJ. Certification: philosophy, goals, and methods, with application to the discipline of infection control practice. AM J INFECT CONTROL 1986;14:11-19.
FORUM
Practice Forum articles should address infection prevention and control practices and related applications of epidemiology. Items should be limited to two to five typed double-spaced pages. Please send items to the Editor, Mary Castle White, RN, MPH, PhD, 155 Marston Ave., San Francisco, CA 94112.
Infection control A new perspective
in public
health:
Dianna C. Hayden, RN, BSN Paducah,
Kentucky
The mission of the Public Health Service is to protect and advance the health of the American people by preventing and controlling disease.’ To fulfill this mission, public health personnel must employ the principles of infection control to deliver services in the safest, most efficient manner. Hospital infection control programs help to provide high levels of patient care through the surveillance, prevention, and control of nosocomial infections.’ They are ineffective, however, as models for public health because they are conducted in settings in which the environment, patient population, and staff are well defined. The environments of community settings are varied and patient populations are fluid. Therefore public health staff members must develop new and innovative programs to achieve the goals of surveillance and of prevention and control of nosocomial infections. The purpose of this article is to describe the Purchase District Health Department’s infection control program, which enables it to deliver services in a safe, efficient manner. BACKGROUND
The Purchase District Health Department serves western Kentucky, which includes eight rural counties that cover 2399 square miles From
the Purchase
Reprint 42066.
requests:
17/1113442
District Dianna
Health Hayden,
Department. RN, Route
2, Mayfield,
KY
with a population of 174,400.3* 4 There are six local hospitals, of which two are regional medical centers. The Health Department itself consists of nine clinical centers, four home health branches, one center for handicapped services, and two administrative offices. During the development of our infection control plan, the organization of the health department had to be carefully considered. Each center within the health department has administrative, nursing, clerical, and environmental service personnel. One organizational problem identified was that of implementing policies in 10 different sites with only one half-time nursing position designated to the program. PROGRAM
DEVELOPMENT
An effective infection control program must include (1) goals and objectives with a timetable to accomplish them, (2) policies and procedures that encompass all aspects of services, (3) in-service programs and implementation of these policies, and (4) an ongoing system for surveillance. Twenty-eight areas related to infection control were identified as being in need of policies. The areas of employee health, basic laboratory procedures, and instrument cleaning/sterilization are briefly discussed here. Employee health. The goal of our employee health program was to use the same concepts of preventive health offered the community while continuing to assess new risks encoun47
American
48
Hayden
INFECTION
tered in the workplace. An initial health history was administered to all employees to determine baseline health data. Laboratory procedures. Because the Health Department has only one comprehensive laboratory, center nurses must collect and prepare body specimens for tests performed on site or transport them to outside laboratories. Safe and uniform laboratory practices had to be developed. Instrument cleaning and sterilization. Characteristically our centers do not have the support services available to hospitals. Sterile and central supply services do not exist as units in our centers; therefore personnel had to be educated in these duties. Comprehensive procedures were needed for the maintenance of a sanitary environment and for the provision of disinfection and the storage of equipment.
IN=SERVICE PROGRAM8 IMPLEMENTATION
AND
An educational program was developed that involved an initial district-wide 2-day inservice workshop. Nurses and nursing personnel, who have the greatest physical contact with patients, also are at greatest risk of transmission of organisms.’ Infection control information is disseminated to the nursing supervisors to ensure a better understanding of the concepts, thus encouraging the supervisors to become advocates for infection control within the centers. Ongoing training ensures that employees will participate in at ‘least one in-service program yearly. The infection control practitioner (ICP) continues to be available for ongoing consultation and for occasions when an incident or a question arises. SURVEILLANCE
AND
REVISION
Wenzel states that “surveillance should ideally provide systematic and continuous observations . . . for the purpose of prevention and control.“5 Because of the geographic location of the health centers, it is not feasible for the ICP to make surveillance visits on a daily or even a weekly basis. Therefore a tool was developed that focused on aspects of infection prevention: in the sanitation of the environment, in the
Journal
of
CONTROL
practice of nursing and laboratory procedures, and in the delivery of environmental services. This enabled the administrator and supervisors to evaluate their health centers from an infection control viewpoint. The initial surveillance visit provided consultation with the ICP, initiated use of the surveillance tool, and evaluated the employees’ immunization status. The administrator and supervisors walked with the ICP throughout the facility, using the surveillance tool as a point of reference. Some of the deficiencies discussed, for example, were inconvenient placement and overfilling of containers for sharps and improper janitorial cleaning and storage. Suggestions to correct these deficiencies included obtaining varying sizes of containers for sharps for the clinic, the laboratory, and the home health settings, storing janitorial chemicals away from public access, and planning a structured schedule for correction, with measurable goals and a timetable for effecting the correction. Employees of the health centers were interviewed individually to establish baseline immunization information on tetanus, measles, rubella, and hepatitis B. The only mandatory screening was a yearly tuberculosis skin test. Employees whose immunizations were not up to date were encouraged to be immunized. These interviews resulted in an increase in the number of protected employees. Thirty-eight tetanus boosters were given, which increased employee protection to 80%. Fifty-five employees are completing hepatitis vaccination, resulting in the protection of 65% of the nursing staff. Measles immunity was identified at 90% either by vaccine, disease, or age. Nine persons were given measles-mumps-rubella vaccine, which brought rubella immunity to 68%. All information from the health history data was entered into the computer, which permits evaluation of the status of immunity of all employees in the event of a communicable disease outbreak or employee incident. ROLE OF THE PRACTITIONER
INFECTION
CONTROL
The role of the ICP includes activities such as collection and analysis of data; planning, implementing, and evaluating infection control
Volume February
18 Number
1
Infection control in public health
1990
measures; education and prevention; development and revision of policy; and consultation and management .6 The ICP in our program is a public health nurse with a basic knowledge of community health and the needs of health centers. She prepared for the ICP role by attending courses on infection control and epidemiology response to communicable outbreaks in the community. It is the goal of the department that as the program develops the ICP’s role will more effectively reflect that described by Pugliese et a1.6 SUMMARY
As public health continues to meet the challenges of old and new health risks, the practice of infection control will be an integral part of its services. The public health infection control program should include effective policies and procedures, in-service programs and implementation, and systems of surveillance specific to each department. Public health personnel must place emphasis on the practice of infection
49
control in the community setting. The ICP who accepts this challenge will be in the forefront of infection control in public health. Infection control is a respected part of the hospital setting and now is the time for the ICP to tailor this program to the public health delivery system.
References RE. PHS commitment to combating HIV in1. Windom fection and AIDS. Public Health Rep 1988;103(suppl l):l-2. 2. Axnick JK, Yarbrough M. Infection control: an integrated approach. St. Louis: CV Mosby, 1984: 1. 3. U.S. Department of Commerce. 1980 census of population: number of inhabitants (Report No. PC80-l-A19). Washington, D.C.: Bureau of the Census, 1982. of Commerce. Kentucky economic sta4. U.S. Department tistics. Washington, D.C.: Bureau of the Census, August 1987. 5. Wenzel RP. Prevention and control of nosocomial infections. Baltimore: Williams & Wilkins, 1987:57,71. 6. Pugliese G, Larson E, Foote SB, Jackson MM, Hierholzer WJ. Certification: philosophy, goals, and methods, with application to the discipline of infection control practice. AM J INFECT CONTROL 1986;14:11-19.
