Infection control policies and guidelines--Scandinavian experience.

In the Scandinavian countries few regulations govern hospital infection control. In Sweden a common procedure manual is used nationwide, consisting of guidelines covering a wide range of nursing and medical procedures performed by the nursing staff. It is revised every fifth year. A recent enquiry to over 150 wards in some 100 hospitals demonstrated that the manual is widely accepted and used. In the other Scandinavian countries, guidelines and policies on a variety of infection control topics have been published.

Nursing priorities and the contribution of the International Federation of Infection Control.

Much thought has been given to the role of the nurse in the future. Concern has been expressed that nurses are becoming preoccupied with technology which, despite the undoubted advantages, is diverting attention from simple prevention and control of infection measures. In countries with minimal resources the appointment of a full-time infection control nurse may not be feasible. Therefore, attempts should be made to train all nurses in the basic principles and practice of the prevention and control of nosocomial infection. This training should be designed to suit the needs of the individual country taking into account the culture, common infections and the patient population. The International Federation of Infection Control should be able to assist with this type of education. The nursing priorities for each country will vary and, whereas handwashing will remain a major priority, routine surveillance may be impracticable. The International Federation of Infection Control which was founded in 1987 is planning to take a lead in helping to set up organizations for infection control workers and to improve communications between organizations in different countries.

Information in infection control.

Effective infection control depends upon a clear understanding of the activities of surveillance, control, communication and management and of the nature and source of information required. Surveillance uses diverse information and computerization of hospital information provides the potential for automated detection of patients at risk of, or affected by, nosocomial infection. Routine visits to all hospital wards by the infection control team is widely advocated but is an inefficient use of a limited resource. 'Targeting' clinical areas with particular problems is more efficient but requires the means to find cases and perform risk assessment through surveillance. While microbiology laboratory reports are effective for case finding, sensitivity and specificity are low. The increasing use of computer held clinical data presents new opportunities for automated surveillance to guide the daily activities of the infection control team. It is essential to stress the importance of infection surveillance to those designing hospital information systems.

The use of personal computers in hospital infection control.

The storage, retrieval and analysis of hospital infection data is best performed by using computers. Many laboratory mainframe systems have infection control modules and there are some commercial programs for personal computers (PCs). An alternative is to use business and statistical PC software. Because of their large customer base these programs are reliable and easy to use yet extremely sophisticated and flexible, and they can be easily customized for use in infection control. Many combinations of software and hardware are available but the ones described here have been used successfully for several years at the Prince of Wales Hospital in Hong Kong.

Microprocessors for auditing the surveillance activity of the Infection Control Nurse.

An important part of the Infection Control Nurse's activity in the UK is the laboratory-based surveillance of patients with infections that are known to be transmissible, i.e. of 'alert' organisms. We have replaced a manual 'T-card' system in which relevant patient information, microbiology and nursing notes are held on all patients yielding 'alert' organisms. The programme is menu driven, requires minimal coding and runs on a microprocessor with a hard disc. The programme enables surveillance patient information to be entered, edited, archived and recorded. Instant retrieval on screen or hard copy includes summarized or full displays of all patients on all wards, sorted by wards, organism, date or risk category. Archived data may be retrieved within minutes and this avoids having to interrogate the whole laboratory database overnight. To illustrate an additional use of the data stored, we analysed the surveillance activities of the Control of Infection Nurse for one year. Of 203 laboratory diagnoses requiring patient surveillance, 30% were viral infections, of which more than two-thirds were caused by hepatitis B virus; of the 142 bacterial isolates, 27% were multiply antibiotic-resistant Enterobacteriaceae, 25% Pseudomonas spp, 12% Salmonella spp., 9% methicillin-resistant Staphylococcus aureus (MRSA), 7% Group A streptococci and 8% meningococci. These isolates resulted in only four outbreaks involving nine patients or staff. This information has proved useful for auditing the nurse's activity and provides evidence for the cost-effectiveness of infection control.

The HELP system and its application to infection control.

The HELP system is a comprehensive hospital information system that is linked to an allied financial data base. The clinical data base integrates information from areas such as admitting, pharmacy, radiology, surgery, pathology, nursing, respiratory therapy, and the clinical laboratories, including microbiology. This allows for the creation of an electronic medical record that contains all the clinical and financial data for each patient. The HELP system combines both communication and advice features through the use of data- and time-driven algorithms. We have used the HELP system to automate the surveillance and analysis of hospital-acquired infections and to identify patients at high risk for nosocomial infection. The expert system features have also been used to suggest alternatives for patients receiving inappropriate antimicrobial therapy, to improve the timing of antibiotic prophylaxis in surgery, and to curtail unnecessarily prolonged prophylaxis. Automated hospital information systems such as HELP can facilitate the investigation of a broad range of infection control, quality improvement, and cost-containment issues.

Motivation to comply with infection control procedures.

This paper addresses the critical issue of motivating hospital staff to comply with standard infection control procedures. Previous psychological assessment of infection control knowledge, attitudes and behaviour has indicated that the reasons for non-compliance are very basic and reflect inter alia a low perception of the importance of the measures and a lack of motivation. It is argued that, although staff have a theoretical awareness of the value of complying with such procedures, in practice these seem to have a low priority. Compliance levels, therefore, are variable and generally of a low order. If recent advances in the fields of social psychology, behavioural psychology and clinical psychology could be imported to hospital medicine, they could have a dramatic impact in infection control. The Elaboration Likelihood Model, an effective theoretical approach to message-based persuasion, and the energizing effects of intrinsic and extrinsic motivational processes are defined. Finally, the implications of these concepts for persuasive intra-hospital communication in infection control are highlighted. They can provide a framework for developing effective infection prevention programmes.

Everything starts with a risk rate. Cleansing, disinfection and sterilisation techniques.

To reduce rates of infection, infection control procedures should be constantly updated. By identifying high, medium and low risk categories of equipment, an infection control programme can target procedures to specific items of use.