Hospital infection into the 1990s

The fifth evolutionary era in infection control: interventional epidemiology

A historical review of infection control over the last 4 decades indicates that the field has evolved from being one whose investigative work laid the foundation for understanding the chain of infection to an influential profession whose research on effective prevention methods have revoluntionized clinical practice throughout the world. Underlying our successes is the fact that growth in the profession has brought with it an enormous expansion in responsibilities, which in turn has impacted, in some cases severely, the personnel and time resources of infection control departments. At the same time, the economic pressures brought on by the upheavals in the business of health care have trickled down wherein it now influences the makeup and effectiveness of infection control programs. To continue with our mission of reducing morbidity and mortality, and perhaps to avoid a diminishing of our own professional influence, it will become essential that new approaches to the management of infection control programs be implemented. The approach must start by incorporating a basic mandate for change in the infection control professional.

Contemporary challenges for hospital epidemiology

According to conventional wisdom, it is time for hospital epidemiologists to look beyond traditional infection control responsibilities and to shoulder an "expanded role," including quality assurance, risk management, and pharmacoepidemiology. Some see this as a matter of survival as the profession reacts to potent external forces that seek to curb the cost of health care while assuring quality service. Infection control specialists, it is argued, have the epidemiologic skills to measure adverse outcomes of hospitalization, adjust for confounding variables, and evaluate the impact of targeted interventions. Before embracing these new responsibilities, however, it should be noted that many hospital epidemiologists would require additional training in basic epidemiologic principles. Although hospital epidemiologists may seek a leadership role in hospital quality assurance and health policy research, they have generally not been innovators in these fields, even in some specific areas relevant to infection control. For example, while hospital epidemiologists have begun to consider severity of illness as a potential confounder in epidemiologic analyses, they have not participated in the development or validation of any of the most widely used indicators. For those hospital epidemiologists who wish to capitalize on their traditional background in infectious diseases, contemporary infection control provides numerous challenges. For example, the epidemiology of many common nosocomial infections, such as bacterial pneumonia in immunocompromised hosts, remains to be defined. Hospital epidemiologists need to incorporate a variety of sophisticated microbiologic methods into their practice to help them trace the spread of nosocomial pathogens. Finally, they should collaborate more closely with clinical and bench investigators in a number of areas, including microbial pathogenesis, immunology, and biotechnology.

The infection control practitioner: an action plan for the 1990s

Some articles have suggested that to survive in the 1990s an infection control practitioner (ICP) will have to be "smarter, brighter, or gone"--they assume that new initiatives for hospital peer review (utilization review, risk management, antibiotic use review, and quality assurance) soon will swallow up the ICP and the infection control program. This article questions that assumption. It reviews data supporting the continuing need for hospital infection control programs and presents information suggesting that the need for the ICP will increase rather than decline during the 1990s. Four essential characteristics for infection control programs are listed, and skills that make the ICP a valuable resource for other peer review programs are described. Several ways that the ICP can (and must) bring this information to the attention of other hospital personnel are suggested. Such actions help assure recognition of the continuing important role of the ICP and the hospital infection control program in each U.S. hospital and long-term care institution.