How many infection control staff do we need in hospitals?

Infection preventionist staffing levels and rates of 10 types of healthcare-associated infections: A 9-year ambidirectional observation

OBJECTIVE

To quantitatively evaluate relationships between infection preventionists (IPs) staffing levels, nursing hours, and rates of 10 types of healthcare-associated infections (HAIs).

DESIGN AND SETTING

An ambidirectional observation in a 528-bed teaching hospital.

PATIENTS

All inpatients from July 1, 2012, to February 1, 2021.

METHODS

Standardized US National Health Safety Network (NHSN) definitions were used for HAIs. Staffing levels were measured in full-time equivalents (FTE) for IPs and total monthly hours worked for nurses. A time-trend analysis using control charts, t tests, Poisson tests, and regression analysis was performed using Minitab and R computing programs on rates and standardized infection ratios (SIRs) of 10 types of HAIs. An additional analysis was performed on 3 stratifications: critically low (2-3 FTE), below recommended IP levels (4-6 FTE), and at recommended IP levels (7-8 FTE).

RESULTS

The observation covered 1.6 million patient days of surveillance. IP staffing levels fluctuated from ≤2 IP FTE (critically low) to 7-8 IP FTE (recommended levels). Periods of highest catheter-associated urinary tract infection SIRs, hospital-onset Clostridioides difficile and carbapenem-resistant Enterobacteriaceae infection rates, along with 4 of 5 types of surgical site SIRs coincided with the periods of lowest IP staffing levels and the absence of certified IPs and a healthcare epidemiologist. Central-line-associated bloodstream infections increased amid lower nursing levels despite the increased presence of an IP and a hospital epidemiologist.

CONCLUSIONS

Of 10 HAIs, 8 had highest incidences during periods of lowest IP staffing and experience. Some HAI rates varied inversely with levels of IP staffing and experience and others appeared to be more influenced by nursing levels or other confounders.

Structure, staffing, and factors affecting infection control nurses: Hospital based exploratory survey- A study protocol

AIM

The overall aim of the study is to develop a module for the structure, staffing, job responsibilities, training and workflow for the hospital Infection Control Department.

DESIGN

An exploratory research design in two phases. Phase 1: Hospital based exploratory survey design. Phase 2: Delphi technique with Focus Group Discussion.

METHOD

Data will be collected through interviewing Infection Control Nurses (ICNs) or infection control in-charge using Infection Prevention and Control Assessment Framework (IPCAF) released by World Health Organization (WHO) in the first phase and Delphi technique in the second phase to determine the problems and solutions for the concerns pertaining to the ICNs. The study is funded by Indian Council of Medical Research from 15 October 2019 for 3 years duration.

DISCUSSION

Healthcare Associated Infection (HAI) affects the care quality of millions of people around the globe. Many researchers have explored the evidence for causes and measures to contain infection. However, there are hardly few researches from the perspective to structure, staffing pattern and factors affecting ICNs. As staffing is considered as a vital component in infection prevention, there is a necessity for optimization to reduce the global burden related to HAI.

IMPACT

This protocol on Structure, staffing, and factors affecting ICN will provide insight into developing strategy, policy or educational module for the ICNs across the country.

TRIAL REGISTRATION

The trial is registered with Central Trial Registry of India (CTRI) with reference ID: CTRI/2020/07/026286.

How much is adequate staffing for infection control? A deterministic approach through the lens of Workload Indicators of Staffing Need

BACKGROUND

Staffing ratios based on hospital beds and norms do not adequately address the requirement of infection preventionists (IP) in hospitals. We, therefore, aimed to determine staffing of IP (nursing category) based on actual workload involved.

METHODS

The study design was quantitative and longitudinal conducted for 1 year. The study was structured around the steps of the World Health Organization's Workload Indicators of Staffing Need (WISN).

RESULTS

We identified infection control activities, support activities and additional activities to be performed by 4 IP with a total available working time of 6,132 hours for an annual workload of 6,238.25 (±372) hours in an acute care hospital with 182 beds and 69,331 annual admissions. Core infection control activities consumed 78% time. Support and additional activities consumed the remaining 22% time. Active surveillance required 44% time and education consumed 32% time. WISN ratio of available staff and required staff was 0.75.

DISCUSSION

A WISN ratio less than 1 suggests inadequate staffing. Therefore, the WISN method recommends 4 IP instead of 3 based on existing workload. We compared our results with the existing quantification-based staffing studies.

CONCLUSIONS

WISN is a valuable method to measure all infection control activities and translate workload into IP (nursing) full time equivalents.

Desempenho dos programas de prevenção e controle de infecções em pequenos hospitais

RESUMO Objetivo Avaliar a conformidade de estrutura e processo dos programas de prevenção e controle de infecções relacionadas à assistência à saúde. Método Estudo prospectivo, transversal, realizado de 2015 a 2016, em pequenos hospitais de até 70 leitos de uma região do estado de São Paulo. Foram avaliados 4 indicadores previamente validados, expressos em índice de conformidade (porcentagem em relação aos itens avaliados). Resultados Dentre os 27 hospitais recrutados, 14 consentiram em participar. Os valores médios de conformidade para cada indicador foram: Estrutura dos programas 61,0%; Diretrizes operacionais 84,5%; Vigilância epidemiológica 57,9%; Atividades de prevenção 74,5%. Maior conformidade foi observada em hospitais privados (73,9%) e com presença de unidade de terapia intensiva (90,3%). Os hospitais possuíam enfermeiros designados para o programa (92,9%), mas somente 23,1% das instituições privadas atuavam com dedicação exclusiva de seis horas. Conclusão Apenas o indicador referente às Diretrizes Operacionais dos programas avaliados esteve acima de 90% de conformidade na mediana dos hospitais. A maior dispersão dos resultados de conformidade entre os hospitais estudados foi referente ao indicador de Vigilância Epidemiológica.

[Personal preconditions for the prevention of nosocomial infections-guidelines of the German Commission for Hospital Hygiene and Infection Prevention (KRINKO), federal state hygiene regulations in Germany, and compliance by hospitals in Frankfurt am Main]

According to the amendment of the Infection Protection Act (2011), § 23, 8, all federal states in Germany had to pass their own hospital hygiene regulations, in which the need for hygiene specialists in a hospital is defined.This publication explains in its first part the differences between the nationwide Commission for Hospital Hygiene and Infection Prevention (KRINKO) regulations and the hygiene regulations of the different federal states (Hesse, Bavaria, etc.). All federal states - with the exception of Hesse (Hessian Hygiene Regulation, HHygVO) - refer to the relevant expert recommendations of KRINKO.In a second part of this publication, we highlight differences between KRINKO and HHygVO with the example of hospitals in the city of Frankfurt. In 2017, all Frankfurt hospitals had the necessary hygiene specialists (authorized hygiene practitioners, infection control nurses, authorized hygiene care nurses). However, the need for hospital hygienists could not be met, because there is an insufficient number of physician specialists for hospital hygiene available in Germany.The hospitals cannot solve this problem on their own - a political, superordinate decision and regulation must be made, i. e. by regulation and financial support for the advanced training of post-graduate physicians in hygiene. This is important since only experienced hospital hygienists can instruct or supervise hygiene specialists-in-training.

Infection prevention staffing and resources in U.S. acute care hospitals: Results from the APIC MegaSurvey

BACKGROUND

Given the changing nature of infection prevention and control (IPC), appropriate infection preventionist (IP) staffing needs to be established. In this study, we aimed to describe current IP staffing levels and IPC department resources in U.S. acute care hospitals.

METHODS

These data came from the 2015 MegaSurvey conducted by the Association of Professionals in Infection Prevention and Epidemiology. Descriptive statistics and bivariate analyses were conducted to examine differences in respondent, facility, and department characteristics by facility size (average inpatient census ≤100 vs >100).

RESULTS

Data from 1623 respondents were included. Most (72%) had single-site responsibilities and dedicated 76%-100% of their job to IPC (68%). The overall median IP staffing was 1.25 IPs per 100 inpatient census (interquartile range = 1.81). Almost half (46%) represented facilities with daily inpatient census ≤100; the average number of IPs in these facilities was 1.1 (standard deviation = 0.7). The reported number of IPs increased steadily with higher patient census. Significant differences were observed in IP staffing, responsibilities, and support to the IPC department between smaller and larger hospitals.

CONCLUSIONS

This study represents the current snapshot of IP staffing and IPC resources in acute care hospitals. Findings indicate important differences between large and small facilities in staffing and IPC resources. The field of infection prevention would benefit from a comprehensive assessment of IPC department staffing and resource needs.

Positive impact of infection prevention on the management of nosocomial outbreaks at an academic hospital

Aim: Infection prevention (IP) measures are vital to prevent (nosocomial) outbreaks. Financial evaluations of these are scarce. An incremental cost analysis for an academic IP unit was performed. Material & methods: On a yearly basis, we evaluated: IP measures; costs thereof; numbers of patients at risk for causing nosocomial outbreaks; predicted outbreak patients; and actual outbreak patients. Results: IP costs rose on average yearly with €150,000; however, more IP actions were undertaken. Numbers of patients colonized with high-risk microorganisms increased. The trend of actual outbreak patients remained stable. Predicted prevented outbreak patients saved costs, leading to a positive return on investment of 1.94. Conclusion: This study shows that investments in IP can prevent outbreak cases, thereby saving enough money to earn back these investments.

Expanding Roles of Healthcare Epidemiology and Infection Control in Spite of Limited Resources and Compensation

Objective.

Data on the resources and staff compensation of hospital epidemiology and infection control (HEIC) departments are limited and do not reflect current roles and responsibilities, including the public reporting of healthcare-associated infections. This study aimed to obtain information to assist HEIC professionals in negotiating resources.

Methods.

A 28-question electronic survey was sent via e-mail to all Society for Healthcare Epidemiology of America (SHEA) members in October 2006 with the use of enterprise feedback management solution software. The survey responses were analyzed using Microsoft Excel.

Results.

Responses were received from 526 (42%) of 1,255 SHEA members. Of the respondents, 84% were doctors of medicine (MDs) or doctors of osteopathy (DOs), 6% were registered nurses, and 21% had a master of public health or master of science degree. Sixty-two percent were male (median age range, 50-59 years). Their practice locations varied across the United States and internationally. Two-thirds of respondents practiced in a hospital setting, and 63% were the primary or associate hospital epidemiologist. Although 91% provided HEIC services, only 65% were specifically compensated. In cases of antimicrobial management, patient safety, employee health, and emergency preparedness, 75%-80% of respondents provided expertise but were compensated in less than 25% of cases. Of the US-based MD and DO respondents, the median range of earnings was $151,000-$200,000, regardless of their region (respondents selected salary ranges instead of specifying their exact salaries). Staffing levels varied: the median number of physician full-time equivalents (FTEs) was 1.0 (range, 1-5); only about 25% of respondents had 3 or more infection control practitioner FTEs.

Conclusions.

Most professionals working in HEIC have had additional training and provide a wide, growing range of services. In general, only traditional HEIC work is compensated and at levels much less than the time dedicated to those services. Most HEIC departments are understaffed. These data are essential to advocate for needed funding and resources as the roles of HEIC departments expand.

Developing a model to assess optimum infection control workforce in acute care settings

BACKGROUND

Little research has been completed to assess the numbers of infection prevention and control personnel employed or optimal size and composition of infection control teams.

METHODS

Acute national health hospital organizations in England were requested to provide information about the numbers of infection prevention and control personnel employed and weekly hours contributed by each occupational group under the United Kingdom's Freedom of Information legislation. The relationship between capacity of the infection prevention and control workforce, size of the inpatient population, and routinely collected surveillance data for health care-associated infection were explored.

RESULTS

There were 137 (85%) National Health Service (NHS) hospital organizations that responded. The number of infection prevention and control nurses ranged from 1-16 per organization. A total of 46 (33.6%) reported that they received no clinical microbiology sessions, and for 11 (8%) input was inadequate. An antibiotic pharmacist was reported to be employed in 107 (78.1%) organizations. Few infection prevention and control teams reported receiving the following: 1. managerial support, 2. being represented on committees where decisions about resource allocation were made, or 3. assistance with administration.

CONCLUSION

Despite the priority that infection prevention and control have received in the United Kingdom over the last 10 years, many infection prevention and control teams appear underresourced.

Evaluation of the effectiveness of an infection control program in adult intensive care units: a report from a middle-income country

BACKGROUND

The rates of hand hygiene improvement and health care-associated infections (HAIs) were evaluated after the introduction in 2004 of an infection surveillance and prevention program at a university teaching hospital in a low- to middle-income country.

METHODS

Data on hand hygiene compliance, HAI rate, multiresistant organisms, and antibiotic consumption in 4 adult intensive care units (ICUs; medical, general surgery, anesthesiology and reanimation, and neurosurgery) were collected retrospectively for each year from 2004 to 2012. Negative binomial regression modeling with a log link was used to adjust for overdispersion in observations, and the first year of observations served as the baseline for comparing changes in incidence rate ratio (IRR) over the subsequent years.

RESULTS

Total hand hygiene compliance improved from 30.5% in 2004 to 43.5% by 2010 (IRR, 1.3; P <.0001) and reached 63.8% by 2012 (IRR, 1.9; P < .0001). The HAI rate was 42.6/1,000 patient-days at baseline and increased significantly thereafter until 2012, when it decreased by 20% to 33.6/1,000 patient-days (IRR, 0.8; P = .001). The rate of central line-associated bloodstream infection was 7.85 (95% confidence interval [CI], 5.89-10.26)/1,000 catheter-days in 2004 and increased to 12.4 (95% CI, 9.98-14.39)/1,000 catheter-days in 2012 (IRR, 1.5; P = .024). The rate of ventilator-associated pneumonia remained stable from the 2004 baseline rate of 31.66/1,000 ventilator-days to the 2012 rate of 24.04/ 1,000 ventilator-days (IRR, 0.88; P = .574). The rate of catheter-associated urinary tract infection remained relatively stable between 2004 and 2012 (from 7.92/1,000 catheter-days to 4.97/1,000 catheter-days; P = .101). The rate of methicillin-resistant Staphylococcus aureus infection was 6.24/1,000 patient-days at baseline and decreased significantly to 0.73/1,000 patient-days by 2007 (IRR, 0.13; P <.001) and continued to remain below 2/1,000 patient-days for the next 5 years. The rate of Pseudomonas aeruginosa infection decreased significantly from 8.66/1,000 patient-days in 2004 to 6.09/1,000 patient-days in 2010 (IRR, 0.72; P = .026) and to 5.44/1,000 patient-days by 2012 (IRR, 0.63; P = .002). The rate of Acinetobacter baumannii infection was 14.3/1,000 patient-days at baseline, decreased significantly by 2005 (IRR, 0.73; P = .012), fluctuated between 2006 and 2010, and then decreased significantly to 10.44/1,000 patient-days in 2011 (IRR, 0.74; P = .007) and then to 7.6/1,000 patient-days in 2012 (IRR, 0.53; P < .001). Antibiotic consumption did not decrease noticeably over the 9-year study period.

CONCLUSIONS

Hand hygiene improved in all of the ICUs evaluated. Measuring changes in HAI rates in a single health care setting can be statistically challenging, and a bias in the detection rates is not uncommon in the early years of a new infection prevention program. Here, for the first time, implementation of an infection surveillance and prevention program was associated with a reduction in HAI rate.

[Validation of the structure and resources of nosocomial infection control team in hospitals ascribed to VINCat program in Catalonia, Spain]

The main objective of this study was to validate the structure of the infection control team (ICT) in the hospitals adhered to VINCat program and secondary objective was to establish the consistency of resources of each center with the requirements established by the program. Qualitative research consisting of an ethnographic study using participant observation during the years 2008-2010. The centers were stratified in three groups by complexity and beds. The instrument was a semistructured interview to members of the ICT. The transcription of the interview was sent to informants for validation. In November 2010 a questionnaire regarding human resources and number hours dedicated to the ICT was sent. During 2008-2010, 65 centers had been adhered to VINCat program. In 2010, the ICT of Group I hospitals had a mean of two physician, one in full-time and one nurse for every 230 beds. In Group II, one physician part-time and one nurse per 180 beds and in Group III a physician and a nurse for every 98 beds, both part-time. In 2010, all hospitals had a structured ICT, an operative infection committee, and a hospital member representing the center at the program as well as enough electronic resources. The hospitals participating in the program have now VINCat an adequate surveillance structure and meet the minimum technical and human resources required to provide high-quality data. However human resources are not guaranteed.

Healthcare-associated infections at intensive care unit of department of anesthesiology and intensive medicine at Martin Faculty Hospital

We analyzed the occurrence of healthcare-associated infections (HAl) at intensive care unit of the Department of Anesthesiology and Intensive Medicine of Martin Faculty Hospital in 2008. We performed a retrospective-prospective observation according the protocol of European HELICS (Hospital in Europe Link for Infection Control and Surveillance) system. We found 11 HAl (4.45%) which on average prolonged the length of hospitalization by 6 days. The most frequent localisation of HAl was the respiratory tract. By our own observation we found the same number of HAl cases as it had been reported officially but the observed and reported cases do not match. The surveillance system HELICS uses definitions slightly different from those used in Slovakia. The severity of health status of a patient at admission influences the risk of HAl. We suggest a continuing collaboration on HELICS system with further involvement of all departments of Martin Faculty Hospital and creation of a hospital infection control team. We also suggest an improvement in testing for etiologic agents of HAl and an introduction of methods of molecular epidemiology in diagnostics, as well as quantification of costs related to occurrence of HAl and to assess an implication of automated monitoring system in HAl surveillance.

How much time should long-term care and geriatric rehabilitation facilities (nursing homes) spend on infection control?

BACKGROUND

For hospitals, standards for the required number of infection control personnel are outdated and disputed. Such standards are not even available for long-term care and geriatric rehabilitation facilities (ie, nursing homes). This study addressed the question of how much time nursing homes should spend on infection control.

METHODS

Through group discussions and individual sessions, experienced infection control practitioners, medical microbiologists, and nursing home doctors evaluated the time needed to perform infection control activities in a model nursing home.

RESULTS

The number of hours needed was estimated as 513 per 100 beds, or 154 per 10,000 care-days per year.

CONCLUSION

Given that significant differences can be expected among the various facilities identified as nursing homes, long-term care facilities, or geriatric rehabilitation centers, as well as among countries, the standard that we propose for The Netherlands will not be generally applicable. However, the method we have used to determine this standard can be easily applied in other countries and settings.

Nosocomial infection surveillance and control: current situation in Spanish hospitals

We studied healthcare-associated infection (HCAI) surveillance and control programmes in Spanish hospitals in 2006 and the human resources and materials used. A questionnaire on the structure, organisation and resources for HCAI surveillance and control was sent to all hospitals registered in the 2005 National Catalogue of Hospitals. A total of 237 hospitals (29.8%) responded, representing 55.9% of the beds included in the catalogue. Some 92% of hospitals had a surveillance and control programme, although 29.9% had had it for less than five years. Only 17.4% of hospitals had one infection control nurse per 250 beds, and only 36.2% had one infection control doctor per 500 beds. Surveillance is the main activity of those responsible for surveillance and control, and the most widely used systems are reviews of microbiology laboratory test results and studies of outbreaks, prevalence surveys, the incidence of certain procedures and of infection in critical care areas. Collaboration in multicentre studies is variable. EPINE, the prevalence survey of nosocomial infections in Spain, is performed annually in 80.5% of centres; ENVIN-UCI, a study of the incidence of infection in critically ill patients, is carried out in 24.8%, and the European study of the incidence of surgical infection, HELICS, in 22.7%. Priority should be given to improving specialised human resources and establishing common surveillance and control systems.

Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan

Background

In Japan, as in many other countries, several quality and safety assurance measures have been implemented since the 1990's. This has occurred in spite of cost containment efforts. Although government and hospital decision-makers demand comprehensive analysis of these activities at the hospital-wide level, there have been few studies that actually quantify them. Therefore, the aims of this study were to measure hospital-wide activities for patient safety and infection control through a systematic framework, and to identify the incremental volume of these activities implemented over the last five years.

Methods

Using the conceptual framework of incremental activity corresponding to incremental cost, we defined the scope of patient safety and infection control activities. We then drafted a questionnaire to analyze these realms. After implementing the questionnaire, we conducted several in-person interviews with managers and other staff in charge of patient safety and infection control in seven acute care teaching hospitals in Japan.

Results

At most hospitals, nurses and clerical employees acted as the main figures in patient safety practices. The annual amount of activity ranged from 14,557 to 72,996 person-hours (per 100 beds: 6,240; per 100 staff: 3,323) across participant hospitals. Pharmacists performed more incremental activities than their proportional share. With respect to infection control activities, the annual volume ranged from 3,015 to 12,196 person-hours (per 100 beds: 1,141; per 100 staff: 613). For infection control, medical doctors and nurses tended to perform somewhat more of the duties relative to their share.

Conclusion

We developed a systematic framework to quantify hospital-wide activities for patient safety and infection control. We also assessed the incremental volume of these activities in Japanese hospitals under the reimbursement containment policy. Government and hospital decision makers can benefit from this type of analytic framework and its empirical findings.