Jpn. J. Infect. Dig., 53, 2000

Laboratory and Epidemiology Communications

Workflow from Clean to Dirty, HACCP and Inclusiveness Principles
in Effective Implementation of Hospital Infection ControlHiroshi Ybshikura*International Medical Center ofJapan
Toyama 1‑21‑1, Shinjuku‑ku. TobJo 162‑8655
ComThunicated by Hiroshi Yoshikura(Accepted June 6, 2000)

Control of hospital infection is one of the most important

issues in modem medical practice. Hospital infection is not
only a potential burden on patients but also an economicalburden (1). It prolongs a patient's stay in the hospital, and thus
incur additional expenses for extra treatment and manpower.
In some cases, Other patients are deprived of the opportunityof admission. Thoughits importance is recognizedand several
manuals and guidelines have been published on the topic,

hospital infection control oRen remainsineffective, as reflectedby thefrequentanecdotes in the media about unfortunate casesof hospital infection.
To implement infection control practices more effectively,

this paper proposes the following: (i) a "from clean to dirty"
principle, (ii) the incorporation of the notion of HACCP(Hazard Analysis and Critical Control Point), and (iii) inclu‑
SIVeneSS.

1 A I propose the use ofa pnnciple ofworkflowfrom clean todirty in all infection control practices. "Clean" means anarea free of sources of infection and "dirty" designates anarea witha highpossibility of becoming a source of infeCtion.
Whenever this pnnciple cannot be followed, decontamina‑tion (ex., hand washing) is needed. Two important issues
are involved.

(i ) Proper design of medical units/wards and proper pro‑visions. Patients'rooms with different risks, toiletrooms, disposal rooms, entrances, doctors'and nurses 'rooms, etc. have to be located so that the above prln‑

Fig･ 1 ･ Design ofa ward to meet a principle ofworkflow舟om clean to diny.

ciple can be maintained (Fig. I). Equipment should be

Roomsト10: patients'rooms. Squares in each room indicate beds.

Darker beds are those with a higher possibility of becoming a source oflocated in the correct place.

infection.

(ii) Movement of medical staff, patients, and materials is amajor source of the propagation of pathogens. It isfrom diny to clean. Particularattention is required whenlmportant points of the HACCP system can be adapted
to a hospitalinfection control system, i.C., I ) hazard analysis

nurses, who have the closest contact with patients, movebased on past experience ofhospital infecdons; 2) identifica‑

from one ward to another.

tion ofclinical sedngs which resultedinoutbreaks, as well as
establishment of CCPs; 3) evaluation of present practices

important to check if there is an inverse flux, workflow

2･ HACCP consists or 1) conducting a hazard analysis, 2)
determining the critical control points (CCPs), 3) establish‑

based on these analyses; 4) establishment of corrective

ing critical limit(S), 4) establishing a system to monitor

action; and 5) real‑time monitoring of hospital infections,control of the CCP, 5) establishing the corrective action towhich consists of regular reports about infected patientsbe taken when monitoring indicates that a particular CCP

and about bacterial isolation, all the while taking into

is not under control, 6) establishing procedures for verifica‑

account geographical distribution (Fig. 2). Identification

tion to confirm that the HACCP system is working effec‑

of potential sources of infection and sharing the informa‑

tively, and 7) establishing documentation co?ceming alltion with the entire medical staff of a particular unit isprocedures and records appropriate to these pnnciples andtheir application (2).

Monitoring lS not Just fわr the pu叩OSe Or Creating good

important for estabhshing properinfection control measures.
reports. It is first and foremost for preventing the spread*Corresponding au仙or: Fax: +8ト3‑5273‑4526, E‑mail: yoshikura

of hospital infections. Hospital records should include
essentialinformation, but they should not be so detailed as@ri. imcj.go.jp
124Jpn. J. Infect. Dis., 53, 2000

0 HepatltlsB● The.sepir,:no.7MR,A●MRSA (arrlerlmmuno‑⊂)comprom暮zedPatlent

1‑10 PatJents'RoomFig. 2. Infection statusdepicted on a map ofa ward.

Month of Year
December JanLJary FebnJ a

Ward 1
Ward 2
Ward 3
Ward 4
Ward 5
Ward 6
Ward 7
Fig. 3. HypothetiCalcase of an MRSA outbreak in a hospital. Each line represents a patientwith MRSA (methicillin‑resistantStapkylococcus aureus). In this example, Ward 5 (brain surgery unit) is the first source of MRSA.

uses of microbiological surveillance data, etc. Though eachto burden busy medical staff.

3. Inc)usiveness is indispensable for the effective implemen‑unit should have its own manual, each hospital should havetation of an infection control program. Each medical uniu

one general guideline to organize activities in different units

ward needs to create a manual specific to that unit. The

into a coherent whole. The monitoring of infections, as shown

manual should be prepared by the entire staff and should
be regularly scrutinized and revised by the entire stag. Sucha manual isintended to save time by being slmPle, straight‑in Fig. 3, is orgreat use.

REFERENCES

forward, Specific to each unit, practicable, and supported

1. Inlander, C. B.,Levin, L S. andWeiner, E. (1988): Medi‑by the entire staff. Published manuals are to be used only

cine on Trial. Pantheon Books, New York, USA.

as references.

RecommendatiOns appeanng ln Several manuals should be

2. Codex Alimentarius Commission, Food and Agricultureincorporated intoinfection control programs. Such recommen‑

Organization and World Health Organization ( 1 998):
Joint FAO/WHO Food Standards Programme. FoodHygiene Basic Texts. WHO and FAO.

dations may Include a list of duties for which the infection

control committee is responsible, as well as roles played by

infection control doctorsand nurses,andanaccount of effective125