Nosocomial tuberculosis prevention measures among two groups of US hospitals, 1992 to 1996.

OBJECTIVE: To compare trends in nosocomial tuberculosis (TB) prevention measures and health-care worker (HCW) tuberculin skin test (TST) conversion of hospitals with HIV-related Pneumocystis carinii pneumonia (PCP) patients and other US hospitals from 1992 through 1996. DESIGN AND SETTING: Surveys in 1992 and 1996 of 38 hospitals with PCP patients in four high-HIV-incidence cities and 136 other US hospitals from the American Hospital Association membership list. PARTICIPANTS: Twenty-seven hospitals with PCP patients and 103 other US hospitals. RESULTS: In 1992, 63% of PCP hospitals and other US hospitals had rooms meeting Centers for Disease Control and Prevention (CDC) criteria (ie, negative air pressure, six or more air exchanges per hour, and air directly vented to the outside) for acid-fast bacilli isolation; in 1996, almost 100% had such isolation rooms. Similarly, in 1992, nonfitted surgical masks were used by HCWs at 60% of PCP hospitals and 68% at other US hospitals, while N95 respirators were used at 90% of PCP hospitals and 83% of other US hospitals in 1996. There was a significant decreasing trend in TST conversion rates among HCWs at both PCP and other US hospitals; however, this trend varied among all hospitals. HCWs at PCP hospitals had a higher risk of TST conversion than those at other US hospitals (relative risk, 1.71; p < 0.0001). CONCLUSION: From 1992 through 1996, PCP and other US hospitals have made similar improvements in their nosocomial TB prevention measures and decreased their HCW TST conversion rate. These data show that most hospitals are compliant with CDC TB guidelines even before the enactment of an Occupational Safety and Health Administration TB standard.

Are US hospitals making progress in implementing guidelines for prevention of Mycobacterium tuberculosis transmission?

BACKGROUND: Outbreaks of tuberculosis (TB) in hospitals have occurred when the Centers for Disease Control and Prevention (CDC) guideline recommendations for preventing the transmission of Mycobacterium tuberculosis were not fully implemented. OBJECTIVE: To determine whether US hospitals are making progress in implementing the CDC guidelines for preventing TB. METHODS: In 1992, we surveyed all public (city, county, Veterans Affairs, and primary medical school-affiliated) US hospitals (n = 632) and 444 (20%) random samples of all private hospitals with 100 beds or more. In 1996, we resurveyed 136 random samples (50%) of all 1992 respondent hospitals with 6 or more TB admissions in 1991. RESULTS: Of the 1076 hospitals surveyed in 1992, 763 (71%) respondents returned a completed questionnaire. Among these, 536 (71%) of 755 reported having rooms that met CDC criteria for acid-fast bacilli isolation, ie, negative air pressure, 6 or more air exchanges per hour, and air directly vented to the outside. The predominant respiratory protective device for health care workers was nonfitted surgical mask and attending physicians were infrequently (50%) included in tuberculin skin-testing programs. In the 1996 resurvey, 103 (76%) of 136 respondents returned a completed questionnaire. Of these, 99 (96%) reported having rooms that met CDC criteria for acid-fast bacilli isolation. The N95 respiratory protective devices were predominantly used by health care workers, and attending physicians were increasingly (69%) included in the hospitals' tuberculin skin-testing programs. CONCLUSIONS: Most US hospitals are making progress in the implementation of CDC guidelines for preventing the transmission of M tuberculosis.

Detecting pediatric nosocomial infections: how do infection control and quality assurance personnel compare?

OBJECTIVE: To compare how well infection control (IC) and quality assurance (QA) personnel in a specialty setting identify the presence, type (nosocomial or community-acquired), and (if nosocomial) site of infection. METHODS: In 1994, we mailed a survey that included 21 pediatric case histories to IC and QA personnel in pediatric settings in the United States (children's hospitals and medical school-affiliated hospitals with pediatric wards of > 30 beds). From the case histories presented, the respondents were asked to determine whether an infection was present and, if so, whether it was nosocomial or community-acquired. If the infection was nosocomial, the respondent was asked to determine the site of the infection (e.g., urinary tract, bloodstream). RESULTS: From the 289 hospitals to which surveys were mailed, 131 respondents (45.3%) completed 212 surveys. Of the 212 returned surveys, 120 (56.6%) were completed by IC personnel and 92 (43.4%) were completed by QA personnel. Among the 183 respondents from acute care pediatric settings, 92.3% of IC personnel (96/104) and 54.4% of QA personnel (43/79) correctly identified at least 75% of the nosocomial infections (n = 14; p < 0.0001). IC and QA personnel were similar in ability to identify community-acquired infection (88/104 vs 70/79, respectively; p = 0.436). IC personnel were significantly more likely than QA personnel to accurately identify the following sites of infection: respiratory tract infection without secondary bloodstream infection, necrotizing enterocolitis, urinary tract infection with and without secondary bloodstream infection, primary bloodstream infection, surgical site infection, gastroenteritis, esophagitis, and clinical sepsis. CONCLUSIONS: Overall, IC personnel were more accurate than QA personnel in determining whether a nosocomial infection was present and in correctly determining most sites of infection. Both IC and QA personnel had difficulty identifying venous infection and respiratory tract infection with secondary bloodstream infection. Both IC and QA personnel could thus benefit from more concise definitions or further training in detection of these sites of nosocomial infections. In addition, QA personnel did not perform overall as well as IC personnel in identifying nosocomial infections and their sites; this finding suggests the need for QA personnel to be provided specific training on detection of nosocomial infections and validation of their ability to do so. Nosocomial infection surveillance should be the responsibility of those trained and proved capable of detecting these infections.