Prevention and control of healthcare-associated infections or HAIs has become the focus of many efforts at the local, national, and international level. Although for decades, infection control professionals and others interested in healthcare epidemiology in healthcare facilities have focused their attention on surveillance and control of HAIs, it is only most recently that the public is demanding accountability for the prevention and control of preventable HAIs. This has led to a movement for public reporting of HAI rates, the passing of legislation in many states requiring public reporting of HAIs, and an intensification of efforts to prevent and control these infections.
In the past, most in infection control used “benchmarking” to self-assess. That is, if their healthcare facilities HAI rate was at or below the median reported rate for other similar facilities (often compared with the Centers for Disease Control and Prevention's [CDC's] National Nosocomial Infections Surveillance [NNIS] system data), then no further action was necessary. However, recent interventions suggest that an even greater proportion of HAIs are preventable than previously estimated. The goal of this fifth edition of Hospital Infections is to provide the reader with the latest in the field of healthcare epidemiology and HAI prevention and control and to provide the tools to move the field of healthcare epidemiology and infection control to zero tolerance, i.e., the goal of preventing all the preventable HAIs that we possibly can.
Over the past several decades, there have been tremendous advances in the field of healthcare epidemiology and infection control. Like the delivery of healthcare, the field of healthcare epidemiology and infection control has moved from surveillance and control of HAIs in hospitals to include all inpatient and outpatient healthcare settings, including long-term care, rehabilitative care, acute, acute step-down, transitional care, etc. Each of these settings has unique issues to address in healthcare epidemiology and infection control. In addition, the field of healthcare epidemiology has advanced to include infectious and non-infectious processes. In this new edition of Hospital Infections, we address many of these issues.
Over half of the authors of chapters in this edition of Hospital Infections are new. Thus, the material is new and updated to include the latest in the field. We have tried to address healthcare epidemiology and infection control issues in surveillance, prevention, patient safety, and more in all settings from the small community hospital to large referral centers, inpatient and outpatient settings. We provide the approaches to surveillance as outlined from the CDC's National Healthcare Safety Network or NHSN; approaches to cost and cost benefit analyses of HAI prevention programs; the risk factors for HAIs and the measures proven to prevent or reduce these infections—focusing on the evidence upon which these recommendations are based.
Antimicrobial-resistant pathogens or ARPs have become a major public health crisis. Since the late 1970s, methicillin-resistant Staphylococcus aureus (MRSA) has become endemic in most healthcare facilities throughout the world (with a few exceptions—such as facilities in Northern Europe and West Australia). During the 1990s, we saw the emergence of vancomycin-resistant enterococcus (VRE) in the United States and, within a decade, it also has become endemic in many healthcare facilities. Increasingly HAIs are being caused by pathogens with greater and greater resistance to antimicrobials. We no longer can rely on the pharmaceutical industry to develop the next great antimicrobial to treat patients with ARP infections. We are returning to the pre-antibiotic era for some of our HAI pathogens—such as the emergence of vancomycin-intermediate or vancomycin-resistant S. aureus or pan-resistant Acinetobacter spp.! The prevention of transmission of these and other ARPs will be dependent upon the implementation of proven infection control measures. Improving the stewardship of antimicrobials may reduce the emergence of such strains, but only the complete adherence to proven infection control measures will prevent the transmission of such strains in our healthcare facilities. Because of the importance of this issue, we have included several chapters addressing the topic from the microbiologic (mechanisms of resistance and how to detect them), epidemiologic (risk factors and modes of transmission) and interventional (evidence-based methods to prevent the emergence or transmission of these pathogens) perspective.
Healthcare epidemiology and infection control activities no longer are just important in developed countries. Rather, the prevention and control of HAIs is a critical component of effective patient safety programs in all healthcare settings in the world. For that reason, we have invited renowned authors from around the world to address critical elements of successful infection prevention and control programs, such as hand hygiene, pandemic influenza, and patient
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safety. We hope that by including the perspective of those throughout the world that we can bring the healthcare epidemiology and infection control communities together and enhance the speed of improvement of infection control and healthcare epidemiology activities in all healthcare facilities throughout the world.
Finally, over the last several years, two areas of infection control have surfaced with great fanfare and media attention. The first is medical errors and patient safety and the second is public reporting of HAI rates. Since the Institute of Medicine (IOM) Report on Medical Errors, greater emphasis has been focused in healthcare facilities on surveillance of and prevention of non-infectious disease adverse events. We have included a chapter on patient safety to increase knowledge in this area and to illustrate how healthcare epidemiology and infection control processes can easily be applied to non-infectious disease adverse events. Many healthcare epidemiology and infection control programs have assumed responsibility for the patient safety program. It is important to remember that HAIs are the major cause of adverse patient events causing morbidity and mortality and the advances made in infection control are testimony to the cost-efficacy of investing over the years in infection prevention and control programs. Despite these advances, the public demands more access to HAI rate data to make informed decisions about their healthcare. Thus, the movement for public reporting of HAI rates was born. We have included a chapter on public reporting of HAI rates. This chapter emphasizes the importance of providing the consumer with validated and risk adjusted rates. We should take the lead in educating legislators, consumers, and others on the advances we have made in the past two decades on calculating risk-adjusted HAI rates for valid inter- or intra-healthcare facility rate comparisons. We are entering an era of zero tolerance for HAIs. The healthcare epidemiology and infection control community should take the enormous advances in knowledge contained in this edition of Hospital Infections and insure that the prevention interventions are fully implemented, so that as many preventable HAIs as possible are prevented, with the ultimate goal being that all preventable HAIs are being prevented. If prevention is primary, action is essential!