Chapter 41. Preventing Health Care–Associated 

Infections 

Amy S. Collins 

Background 

The occurrence and undesirable complications from health care–associated infections (HAIs) 

have been well recognized in the literature for the last several decades. The occurrence of HAIs 

continues to escalate at an alarming rate. HAIs originally referred to those infections associated 

with admission in an acute-care hospital (formerly called a nosocomial infection), but the term 

now applies to infections acquired in the continuum of settings where persons receive health care 

(e.g., long-term care, home care, ambulatory care). These unanticipated infections develop 

during the course of health care treatment and result in significant patient illnesses and deaths 

(morbidity and mortality); prolong the duration of hospital stays; and necessitate additional 

diagnostic and therapeutic interventions, which generate added costs to those already incurred by 

the patient’s underlying disease. HAIs are considered an undesirable outcome, and as some are 

preventable, they are considered an indicator of the quality of patient care, an adverse event, and 

a patient safety issue. 

Patient safety studies published in 1991 reveal the most frequent types of adverse events 

affecting hospitalized patients are adverse drug events, nosocomial infections, and surgical 

complications.1, 2 From these and other studies, the Institute of Medicine reported that adverse 

events affect approximately 2 million patients each year in the United States, resulting in 90,000 

deaths and an estimated $4.5–5.7 billion per year in additional costs for patient care.3

 Recent 

changes in medical management settings have shifted more medical treatment and services to 

outpatient settings; fewer patients are admitted to hospitals. The disturbing fact is that the 

average duration of inpatient admissions has decreased while the frequency of HAIs has 

increased.4, 5 The true incidence of HAIs is likely to be underestimated as hospital stays may be 

shorter than the incubation period of the infecting microorganism (a developing infection), and 

symptoms may not manifest until days after patient discharge. For example, between 12 percent 

and 84 percent of surgical site infections are detected after patients are discharged from the 

hospital, and most become evident within 21 days after the surgical operation.6, 7 Patients 

receiving followup care or routine care after a hospitalization may seek care in a nonacute care 

facility. The reporting systems are not as well networked as those in acute care facilities, and 

reporting mechanisms are not directly linked back to the acute care setting to document the 

suspected origin of some infections. 

Since the early 1980s HAI surveillance has monitored ongoing trends of infection in health 

care facilities.8

 With the application of published evidence-based infection control strategies, a 

decreasing trend in certain intensive care unit (ICU) health care-associated infections has been 

reported through national infection control surveillance9 over the last 10 years, although there has 

also been an alarming increase of microorganism isolates with antimicrobial resistance. These 

changing trends can be influenced by factors such as increasing inpatient acuity of illness, 

inadequate nurse-patient staffing ratios, unavailability of system resources, and other demands 

that have challenged health care providers to consistently apply evidence-based 

recommendations to maximize prevention efforts. Despite these demands on health care workers 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

and resources, reducing preventable HAIs remains an imperative mission and is a continuous 

opportunity to improve and maximize patient safety. 

Another factor emerging to motivate health care facilities to maximize HAI prevention 

efforts is the growing public pressure on State legislators to enact laws requiring hospitals to 

disclose hospital-specific morbidity and mortality rates. A recent Institute of Medicine report 

identified HAIs as a patient safety concern and recommended immediate and strong mandatory 

reporting of other adverse health events, suggesting that public monitoring may hold health care 

facilities more accountable to improve the quality of medical care and to reduce the incidence of 

infections.3

 Since 2002, four States (Florida, Illinois, Missouri, and Pennsylvania) set legislation 

mandating health care organizations to publicly disclose HAIs.10, 11 In 2006, the Association for 

Professionals in Infection Control and Epidemiology (APIC) reported that 14 States have 

mandatory public reporting, and 27 States have other related legislation under consideration.12

Participation in public reporting has not been regulated by the Federal sector at this time. Some 

hospital reporting is intended for use solely by the State health department for generating 

confidential reports that are returned to each facility for their internal quality improvement 

efforts. Other intentions to utilize public reporting may be aimed at comparing rates of HAI and 

subsequent morbidity and mortality outcomes between different hospitals. This approach is 

problematic as there is currently a lack of scientifically validated methods for risk adjusting 

multiple variations (e.g., differences in severity of illnesses in each population being treated) in 

patients’ intrinsic and extrinsic risks for HAIs.13–15 Moreover, data on whether public reporting 

systems have an effective role in reducing HAIs are lacking. 

To assist with generating meaningful data, process and outcome measures for patient safety 

practices have been proposed.13, 14, 16 Monitoring both process and outcome measures and 

assessing their correlation is a model approach to establish that good processes lead to good 

health care outcomes. Process measures should reflect common practices, apply to a variety of 

health care settings, and have appropriate inclusion and exclusion criteria. Examples include 

insertion practices for central intravenous catheters, appropriate timing of antibiotic prophylaxis 

in surgical patients, and rates of influenza vaccination for health care workers and patients. 

Outcome measures should be chosen based on the frequency, severity, and preventability of the 

outcome events. Examples include intravascular catheter-related blood stream infection rates and 

surgical-site infections in selected operations. Although these occur at relatively low frequency, 

the severity is high—these infections are associated with substantial morbidity, mortality, and 

excess health care costs—and there are evidence-based prevention strategies available.17, 18 

Definitions of Health Care-Associated Infections 

The Centers for Disease Control and Prevention (CDC) developed baseline definitions for 

HAIs that were republished in 2004.19 HAIs were defined as those that develop during 

hospitalization but are neither present nor incubating upon the patient’s admission to the hospital; 

generally for those infections that occur more than 48 to 72 hours after admission and within 10 

days after hospital discharge. Some hospitals use these definitions exactly as written; other 

hospitals may use some but not all of the CDC definitions; and other health care facilities may 

need to modify or develop their own definitions. Whatever definition is used, it should be 

consistent within the institution and be the same or similar to those developed by CDC or those 

used by other investigators. Having standard definitions is useful if the health care facility wants 

2 
Preventing Health Care–Associated Infections

to compare surveillance results or performance measures within its various medical/surgical 

specialties, against those of other health care institutions, or with national published data. 

Patient Risk Factors for Health Care–Associated Infections 

Transmission of infection within a health care setting requires three elements: a source of 

infecting microorganisms, a susceptible host, and a means of transmission for the microorganism 

to the host. 

Source of Microorganisms 

During the delivery of health care, patients can be exposed to a variety of exogenous 

microorganisms (bacteria, viruses, fungi, and protozoa) from other patients, health care 

personnel, or visitors. Other reservoirs include the patient’s endogenous flora (e.g., residual 

bacteria residing on the patient’s skin, mucous membranes, gastrointestinal tract, or respiratory 

tract) which may be difficult to suppress and inanimate environmental surfaces or objects that 

have become contaminated (e.g., patient room touch surfaces, equipment, medications). The 

most common sources of infectious agents causing HAI, described in a scientific review of 1,022 

outbreak investigations,20 are (listed in decreasing frequency) the individual patient, medical 

equipment or devices, the hospital environment, the health care personnel, contaminated drugs, 

contaminated food, and contaminated patient care equipment. 

Host Susceptibility 

Patients have varying susceptibility to develop an infection after exposure to a pathogenic 

organism. Some people have innate protective mechanisms and will never develop symptomatic 

disease because they can resist increasing microbial growth or have immunity to specific 

microbial virulence properties. Others exposed to the same microorganism may establish a 

commensal relationship and retain the organisms as an asymptomatic carrier (colonization) or 

develop an active disease process. 

Intrinsic risk factors predispose patients to HAIs. The higher likelihood of infection is 

reflected in vulnerable patients who are immunocompromised because of age (neonate, elderly), 

underlying diseases, severity of illness, immunosuppressive medications, or medical/surgical 

treatments. Patients with alterations in cellular immune function, cellular phagocytosis, or 

humoral immune response are at increased risk of infection and the ability to combat infection. A 

person with a primary immunodeficiency (e.g., anemia or autoimmune disease) is likely to have 

frequently recurring infections or more severe infections, such as recurrent pneumonia.21

Secondary immunodeficiencies (e.g., chemotherapy, corticosteroids, diabetes, leukemia) increase 

patient susceptibility to infection from common, less virulent pathogenic bacteria, opportunistic 

fungi, and viruses. Considering the severity of a patient’s illness in combination with multiple 

risk factors, it is not unexpected that the highest infection rates are in ICU patients. HAI rates in 

adult and pediatric ICUs are approximately three times higher than elsewhere in hospitals.22

Extrinsic risk factors include surgical or other invasive procedures, diagnostic or therapeutic 

interventions (e.g., invasive devices, implanted foreign bodies, organ transplantations, 

immunosuppressive medications), and personnel exposures. According to one review article, at 

least 90 percent of infections were associated with invasive devices.23 Invasive medical devices 

bypass the normal defense mechanism of the skin or mucous membranes and provide foci where 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

pathogens can flourish, internally shielded from the patient’s immune defenses. In addition to 

providing a portal of entry for microbial colonization or infection, these devices also facilitate 

transfer of pathogens from one part of the patient’s body to another, from health care worker to 

patient, or from patient to health care worker to patient. Infection risk associated with these 

extrinsic factors can be decreased with the knowledge and application of evidence-based 

infection control practices. These will be discussed in further detail in Chapter 42, “Targeting 

Health Care–Associated Infections: Evidence-Based Strategies.” 

Prolonged hospitalization, due to a higher acuity of illness, contributes to host susceptibility 

as there is more opportunity to utilize invasive devices and more time for exposure to exogenous 

microorganisms. These patients are also more susceptible to rapid microbial colonization as a 

consequence of the severity of the underlying disease, depending on the function of host 

defenses and the presence of risk factors (e.g., age, extrinsic devices, extended length of stay). 

Exposure to these colonizing microorganisms is from such sources as (1) endemic pathogens 

from an endogenous source, (2) hospital flora in the health care environment, and (3) hands of 

health care workers. A study related to length of hospitalization examining adverse events in 

medical care indicated that the likelihood of experiencing an adverse event increased 

approximately 6 percent for each day of hospital stay. The highest proportion of adverse events 

(29.3 percent) was not related to surgical procedures but linked instead to the subsequent 

monitoring and daily care lacking proper antisepsis steps.24

Means of Transmission 

Among patients and health care personnel, microorganisms are spread to others through four 

common routes of transmission: contact (direct and indirect), respiratory droplets, airborne 

spread, and common vehicle. Vectorborne transmissions (from mosquitoes, fleas, and other 

vermin) are atypical routes in U.S. hospitals and will not be covered in this text. 

Contact transmission. This is the most important and frequent mode of transmission in the 

health care setting. Organisms are transferred through direct contact between an infected or 

colonized patient and a susceptible health care worker or another person. Patient organisms can 

be transiently transferred to the intact skin of a health care worker (not causing infection) and 

then transferred to a susceptible patient who develops an infection from that organism—this 

demonstrates an indirect contact route of transmission from one patient to another. An infected 

patient touching and contaminating a doorknob, which is subsequently touched by a health care 

worker and carried to another patient, is another example of indirect contact. Microorganisms 

that can be spread by contact include those associated with impetigo, abscess, diarrheal diseases, 

scabies, and antibiotic-resistant organisms (e.g., methicillin-resistant Staphylococcus aureus

[MRSA] and vancomycin-resistant enterococci [VRE]). 

Respiratory droplets. Droplet-size body fluids containing microorganisms can be generated 

during coughing, sneezing, talking, suctioning, and bronchoscopy. They are propelled a short 

distance before settling quickly onto a surface. They can cause infection by being deposited 

directly onto a susceptible person’s mucosal surface (e.g., conjunctivae, mouth, or nose) or onto 

nearby environmental surfaces, which can then be touched by a susceptible person who 

autoinoculates their own mucosal surface. Examples of diseases where microorganisms can be 

spread by droplet transmission are pharyngitis, meningitis, and pneumonia. 

Airborne spread. When small-particle-size microorganisms (e.g., tubercle bacilli, varicella, 

and rubeola virus) remain suspended in the air for long periods of time, they can spread to other 

people. The CDC has described an approach to reduce transmission of microorganisms through 

4 
Preventing Health Care–Associated Infections

airborne spread in its Guideline for Isolation Precautions in Hospitals.25 Proper use of personal 

protective equipment (e.g., gloves, masks, gowns), aseptic technique, hand hygiene, and 

environmental infection control measures are primary methods to protect the patient from 

transmission of microorganisms from another patient and from the health care worker. Personal 

protective equipment also protects the health care worker from exposure to microorganisms in 

the health care setting. 

Common Vehicle. Common vehicle (common source) transmission applies when multiple 

people are exposed to and become ill from a common inanimate vehicle of contaminated food, 

water, medications, solutions, devices, or equipment. Bacteria can multiply in a common vehicle 

but viral replication can not occur. Examples include improperly processed food items that 

become contaminated with bacteria, waterborne shigellosis, bacteremia resulting from use of 

intravenous fluids contaminated with a gram-negative organism, contaminated multi-dose 

medication vials, or contaminated bronchoscopes. Common vehicle transmission is likely 

associated with a unique outbreak setting and will not be discussed further in this document. 

Responsibility for Risk Reduction 

Infection Control Department’s Program Responsibilities 

In 1985, the Study of the Efficacy of Nosocomial Infection Control (SENIC) project was 

published, validating the cost-benefit savings of infection control programs.8

 Infection control 

programs were proven to be effective as hospitals with certain practices reduced their infection 

rates by 32 percent, compared with an increase of 18 percent in hospitals without these 

components over a 5-year period.8, 26 Essential components of effective infection control 

programs included conducting organized surveillance and control activities, a trained infection 

control physician, an infection control nurse for every 250 beds, and a process for feedback of 

infection rates to clinical care staff. These programmatic components have remained consistent 

over time and are adopted in the infection control standards of the Joint Commission (formerly 

the Joint Commission on Accreditation of Healthcare Organizations, JCAHO). The evolving 

responsibility for operating and maintaining a facility-wide effective infection control program 

lies within many domains. Both hospital administrators and health care workers are tasked to 

demonstrate effectiveness of infection control programs, assure adequate staff training in 

infection control, assure that surveillance results are linked to performance measurement 

improvements, evaluate changing priorities based on ongoing risk assessments, ensure adequate 

numbers of competent infection control practitioners, and perform program evaluations using 

quality improvement tools as indicated. 

Infection Control Personnel 

It has been demonstrated that infection control personnel play an important role in preventing 

patient and health care worker infections and preventing medical errors. An infection control 

practitioner27 (ICP) is typically assigned to perform ongoing surveillance of infections for 

specific wards, calculate infection rates and report these data to essential personnel, perform staff 

education and training, respond to and implement outbreak control measures, and consult on 

employee health issues. This specialty practitioner gains expertise through education involving 

infection surveillance, infection control, and epidemiology from current scientific publications 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

and basic training courses offered by professional organizations or health care institutions.28, 29

The Certification Board of Infection Control offers certification that an ICP has the standard core 

set of knowledge in infection control.30, 31, 32

Over time, the workload responsibilities of the ICP have significantly increased to 

encompass additional administrative functions and regulatory compliance reporting, sometimes 

covering prevention of infection activities in other facilities that belong to the health care system 

(e.g., long-term care, home care, and outpatient settings). The expanding scope of ICP 

responsibilities being performed with limited time and shrinking resources has created an 

imbalance in meeting all tasks, leading to regular completion of only essential functions and 

completing less essential functions when time permits. In a 2002 ICP survey examining resource 

allocations, the activity consuming the greatest amount of mean estimated time was surveillance, 

followed by education, prevention strategies to control transmission, infection control program 

communication, and outbreak control. In examining the tasks and the time allocations necessary 

to complete essential infection control responsibilities, a recent expert review panel 

recommended new and safer staffing allocations: 1 full-time ICP for every 100 occupied beds. 

Further staffing levels and recommendations are included for different types of health care 

facilities by bed size.33 To maximize successful completion of current reporting requirements 

and strategies for the prevention of infection and other adverse events associated with the 

delivery of health care in the entire spectrum of health care settings, infection control personnel 

and departments must be expanded.34

Nursing Responsibilities 

Clinical care staff and other health care workers are the frontline defense for applying daily 

infection control practices to prevent infections and transmission of organisms to other patients. 

Although training in preventing bloodborne pathogen exposures is required annually by the 

Occupational Safety and Health Administration, clinical nurses (registered nurses, licensed 

practical nurses, and certified nursing assistants) and other health care staff should receive 

additional infection control training and periodic evaluations of aseptic care as a planned patient 

safety activity. Nurses have the unique opportunity to directly reduce health care–associated 

infections through recognizing and applying evidence-based procedures to prevent HAIs among 

patients and protecting the health of the staff. Clinical care nurses directly prevent infections by 

performing, monitoring, and assuring compliance with aseptic work practices; providing 

knowledgeable collaborative oversight on environmental decontamination to prevent 

transmission of microorganisms from patient to patient; and serve as the primary resource to 

identify and refer ill visitors or staff. 

Prevention Strategies 

Multiple factors influence the development of HAIs, including patient variables (e.g., acuity 

of illness and overall health status), patient care variables (e.g., antibiotic use, invasive medical 

device use), administrative variables (e.g., ratio of nurses to patients, level of nurse education, 

permanent or temporary/float nurse), and variable use of aseptic techniques by health care staff. 

Although HAIs are commonly attributed to patient variables and provider care, researchers have 

also demonstrated that other institutional influences may contribute to adverse outcomes.35, 36 To 

encompass overall prevention efforts, a list of strategies are reviewed that apply to the clinical 

6 
Preventing Health Care–Associated Infections

practice of an individual health care worker as well as institutional supportive measures. 

Adherence to these principles will demonstrate that you H.E.L.P. C.A.R.E. This acronym is used 

to introduce the following key concepts to reduce the incidence of health care–associated 

infections. It emphasizes the compassion and dedication of nurses where their efforts contribute 

to reduce morbidity and mortality from health care–associated infections. 

Hand Hygiene 

...so they shall wash their hands and their feet, that they die not: 

and it shall be a statute for ever to them... 

Exodus 30:21 Revised Standard Version 

Overview. For the last 160 years, we have had the scientific knowledge of how to reduce 

hand contamination and thereby decrease patient infections from the seminal work on hand 

washing by the Hungarian obstetrician, Ignaz Semmelweis. Epidemiologic studies continue to 

demonstrate the favorable cost-benefit ratio and positive effects of simple hand washing for 

preventing transmission of pathogens in health care facilities.37, 38 The use of antiseptic hand 

soaps (i.e., ones containing chlorhexidine) and alcohol-based hand rubs also effectively reduce 

bacterial counts on hands when used properly. Even though the clear benefits of hand washing 

have been proven in multiple settings, the lack of consistent hand-washing practices remains a 

worldwide issue. In a resource-poor area of Pakistan, a recent household hand-washing campaign 

demonstrated a 50 percent lower incidence of pneumonia in children younger than 5 years 

compared to households that did not practice hand washing. Children under 15 years in handwashing households had a 53 percent lower incidence of diarrhea and a 34 percent lower 

incidence of impetigo. Hand washing with plain soap prevented the majority of illnesses causing 

the largest number of childhood deaths globally.39 The World Alliance for Patient Safety, formed 

by the World Health Organization, has adopted infection reduction programs—in both developed 

and developing countries—as its first goal.40, 41 The World Alliance for Patient Safety advocates 

a “clean care is safer care” program, in which health care leaders sign a pledge to take specific 

steps to reduce HAIs in their facilities. Hand hygiene is the first focus in this worldwide initiative. 

Understaffing and hand hygiene. Hospitals with low nurse staffing levels and patient 

overcrowding leading to poor adherence to hand hygiene have been associated with higher 

adverse outcome rates and hospital outbreak investigations.34, 42, 43 In an ICU setting,44 it was 

demonstrated that understaffing of nurses can facilitate the spread of MRSA through relaxed 

attention to basic infection control measures (e.g., hand hygiene). In a neonatal ICU outbreak,45

the daily census was above the maximum capacity (25 neonates in a unit designed for 15), and 

the number of assigned staff members was fewer than the number necessitated by the workload, 

which resulted in relaxed attention to basic infection-control measures (use of multidose vials 

and hand hygiene). During the highest workload demands, staff washed their hands before 

contacting devices only 25 percent of the time, but hand washing increased to 70 percent after 

the end of the understaffing and overcrowding period. Ongoing surveillance determined that 

being hospitalized during this period was associated with a fourfold increased risk of acquiring 

an HAI. These studies illustrate an association between staffing workload, infections, and 

microbial transmission from poor adherence to hand hygiene policies. 

Time demands. A perceived obstacle is that time to complete patient care duties competes 

with time needed for hand washing, particularly in technically intense settings such as an ICU. 

Hospital observational studies demonstrate that the frequency of hand washing varies between 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

hospital wards and occurs an average of 5 to 30 times per shift, with more hand washing 

opportunities in an ICU.46 With time limitations due to patient acuity demands or nurse-patient 

ratios and limited availability of sinks, the use of waterless, alcohol-based hand rubs has been 

shown to improve health care workers’ compliance with hand hygiene practices in the ICU.47

Hand washing behaviors. Observational studies have found that on average, health care 

workers adhere to recommended hand hygiene procedures 40 percent of the time (with a range of 

5 to 80 percent).44 These studies implemented various interventions to improve hand washing, 

but summarized effects by measuring responses over a short time frame, without demonstrating 

long-lasting behavioral improvements. Two studies demonstrated the use of multidisciplinary 

interventions to change the organizational culture on frequency of hand washing that resulted in 

sustained improvements during a longer followup time period.48, 49

Behavioral theories that examine the relationship of multiple factors affecting behavioral 

choices have been applied to the complex issue of hand washing compliance. These theories 

illustrate the influence of the individual intention to perform hand washing and organizational 

influences that affect the outcome behavior. The Theory of Planned Behavior has been studied in 

this context, acknowledging that the intention to wash hands involves a person’s (1) attitude 

whether or not the behavior is beneficial to themselves, (2) perception of pressure from peers, 

and (3) perceived control on the ease or difficulty in performing the behavior.50–53 These 

perceptions are also influenced by the strength of the person’s beliefs about the significance of 

the outcomes of the behavior; the normative beliefs, which involve the individual evaluation of 

peer expectations; and control beliefs, which are based on a person’s perception of their ability to 

overcome obstacles that obstruct their completion of the behavior. 

Monitoring compliance. Although standards for hand hygiene practices have been 

published with an evidence-based guideline44 and professional collaborations have produced the 

How-to-Guide: Improving Hand Hygiene,54 there is no standardized method or tool for 

measuring adherence to institutional policy. Varying quality improvement methodologies and a 

lack of consensus on how to measure hand hygiene compliance have made it difficult to 

determine the effectiveness of hand hygiene expectations within and across health care settings. 

The Joint Commission has instituted a partnership with major infection control leadership 

organizations in the United States and abroad to identify best approaches for measuring 

compliance with hand hygiene guidelines in health care organizations though its Consensus 

Measurement in Hand Hygiene (CMHH) project. The participating organizations include APIC, 

CDC, the Society for Healthcare Epidemiology of America, the World Health Organization 

World Alliance for Patient Safety, the Institute for Healthcare Improvement, and the National 

Foundation for Infectious Diseases. The final product of this project, due to be completed in 

early 2008, will be an educational monograph that recommends best practices for measuring 

hand hygiene compliance.55

Summary. Hand hygiene adherence and promotion involve multiple factors at the individual 

and system level to provide an institutional safety climate for patients and health care staff. 

Methods used to promote improved hand hygiene require multidisciplinary participation to 

identify individual beliefs, adherence factors, and perceived barriers. Program successes have 

been summarized and should be reviewed to establish improved hand hygiene as a priority 

program at your facility.44, 56, 57

8 
Preventing Health Care–Associated Infections

Hand Hygiene: Key Points 

• The practice of appropriate hand hygiene and glove usage is a major contributor to patient safety and reduction 

in HAIs. It is more cost effective than the treatment costs involved in a health care–associated infection. 

• Joint Commission infection control standards include hand washing and HAI sentinel event review, which are 

applicable to ambulatory care, behavioral health care, home care, hospitals, laboratories, and long-term care 

organizations accredited by the Joint Commission. 

• Hand hygiene is the responsibility of the individual practitioner and the institution. Developing a patient safety 

culture backed by administrative support to provide resources and incentives for hand washing is crucial to a 

successful outcome. 

• Hand hygiene promotion should be an institutional priority. 

• Select methods to promote and monitor improved hand hygiene. Monitor outcomes of adherence to hand 

hygiene in association with reduced incidence of HAI. 

• Establish an evaluation model to recognize missed opportunities for appropriate hand hygiene. 

Environmental Cleanliness 

The health care environment surrounding a patient contains a diverse population of 

pathogenic microorganisms that arise from a patient’s normal, intact skin or from infected 

wounds. Approximately 106 flat, keratinized, dead squamous epithelium cells containing 

microorganisms are shed daily from normal skin,58 and patient gowns, bed linens, and bedside 

furniture can easily become contaminated with patient flora. Surfaces in the patient care setting 

can also be contaminated with pathogenic organisms (e.g., from a patient colonized or infected 

with MRSA, VRE, or Clostridium difficile) and can harbor viable organisms for several days. 

Contaminated surfaces, such as blood pressure cuffs, nursing uniforms, faucets, and computer 

keyboards,59, 60 can serve as reservoirs of health care pathogens and vectors for crosscontamination to patients. Studies have demonstrated that health care workers acquire 

microorganisms on gloved hands without performing direct patient contact and when touching 

surfaces near a colonized patient.59, 61 Another study determined that a health care worker’s hand 

became contaminated after entering a regular patient’s room (one who was not on contact 

precautions) and only touching common surfaces close to the patient (bed rails, bedside table), 

without direct patient contact. The same hand contact was done by other personnel in unoccupied 

rooms that had been terminally cleaned after patient discharge. Ungloved hands became 

contaminated with low levels of pathogenic microorganisms more than 50 percent of the time, 

even from surfaces in rooms that had been terminally cleaned after patient discharge.62 It is 

important to consider this likelihood of hand contamination could occur (contamination would 

also apply to the external surface of gloves, if worn) and to perform routine hand hygiene to bare 

hands or ungloved hands to reduce hand contamination before touching clean, general-use 

surfaces (e.g., computer keyboard, telephone, med cart, medical record, cleaning supplies, etc.). 

Proper disinfection of common surfaces and proper hand hygiene procedures (after direct contact 

to surfaces or contact with glove usage) is also critically important to reduce direct or indirect 

routes of transmission.63 Persistence of environmental contamination after room disinfection can 

occur and has been recently demonstrated to increase the risk of transmission to the next 

susceptible room occupants.64–66

Thus, patients with known colonization or diseases with multi-drug-resistant organisms or 

Clostridium difficile require Contact Precautions in addition to the Standard Precautions to 

reduce the risk of transmission from the patient and the contaminated environment to others. 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Nurses can ensure clean medical equipment is used between patients and can work with 

environmental services personnel to maximize clean conditions in and around patient rooms. It is 

necessary to consistently perform hand hygiene after routine patient care or contact with 

environmental surfaces in the immediate vicinity of the patient. Infection control procedures are 

recommended to reduce cross-contamination under the following situations:67

1. Use EPA-registered chemical germicides for standard cleaning and disinfection of 

medical equipment that comes into contact with more than one patient. 

2. If Clostridium difficile infection has been documented, use hypochlorite-based products 

for surface disinfection as no EPA-registered products are specific for inactivating the 

spore form of the organism. 

3. Ensure compliance by housekeeping staff with cleaning and disinfection procedures, 

particularly high-touch surfaces in patient care areas (e.g., bed rails, carts, charts, bedside 

commodes, doorknobs, or faucet handles). 

4. When contact precautions are indicated for patient care (e.g., MRSA, VRE, C. difficile, 

abscess, diarrheal disease), use disposable patient care items (e.g., blood pressure cuffs) 

wherever possible to minimize cross-contamination with multiple drug-resistant 

microorganisms. 

5. Advise families, visitors, and patients regarding the importance of hand hygiene to 

minimize the spread of body substance contamination (e.g., respiratory secretions or fecal 

matter) to surfaces. 

A patient safety goal could be to adopt a personal or an institutional pledge, similar to the 

following: I (or name of health care facility) am committed to ensuring that proper infection 

control and environmental disinfection procedures are performed to reduce cross-contamination 

and transmission so that a person admitted or visiting to this facility shall not become newly 

colonized or infected with a bacterium derived from another patient or health care worker’s 

microbial flora.

Leadership 

Health care workers dedicate enormous effort to providing care for complex medical needs 

of patients, to heal, to continuously follow science to improve the quality of care—all the while 

consciously performing to the best of their ability to Primum non nocere (First, do no harm). 

Though medical errors and adverse events do occur, many can be attributed to system problems 

that have impacted processes used by the health care worker, leading to an undesired outcome. 

Health care workers evaluate their professional impact based on outcomes that demonstrate that 

medical and nursing orders are completed properly, that a sentinel event did not occur, clinical 

judgment was properly utilized to improve patient care, and that most patients leave in stable or 

better health than when they arrived. With all the complicated patient care administered, if the 

patient did not acquire an infection during a hospitalization, is that an indication that all patient 

care interactions were practiced aseptically? Or could the lack of infection be attributed to some 

process interactions where the patient received a microbial exposure that was less than the 

threshold needed to acquire an infection or, fortuitously, the patient had enough natural 

immunity to ward off a potential infection? Although success is measured by an outcome with or 

without infection, we should consistently practice in such a manner to reduce patient exposure to 

exogenous microorganisms, which would consequently reduce the risk of infection. 

Responsibility for risk reduction involves the institution administrators, directors, and 

individual practitioners. It is clear that leaders drive values, values drive behaviors, and 

10 
Preventing Health Care–Associated Infections

behaviors drive performance of an organization. The collective behaviors of an organization 

define its culture. The engagement of nursing leaders to collaborate with coworkers and hospital 

administrators in safety, teamwork, and communication strategies are critical requirements to 

improve safe and reliable care. Developed and applied concurrently, they weave a supporting 

framework for the effective implementation of new technologies and evidence-based practices.68

If patients are not receiving all the evidence-based care that is indicated (regardless of a 

noninfectious outcome measure), then we have a professional obligation to demonstrate 

leadership to develop the methods to improve that care. The challenge is how to develop and 

sustain the change necessary to translate infection prevention knowledge into everyday clinical 

practice. As each person accepts his or her role in that responsibility, that leadership and role 

model example will influence a standard culture and expectation for all health care workers and 

support personnel to implement best practices.

Each institution must communicate the evidence-based practices to health care staff, have 

access to expertise about infection control practices, employ the necessary resources and 

incentives to implement change, and receive real-time feedback of national and comparative 

hospital-specific data. 

Health care institutions simply must expect more reliable performance of essential 

infection-control practices, such as hand hygiene and proper use of gloves. It is no 

longer acceptable for hospitals with substandard adherence to these basic 

interventions to excuse their performance as being no worse than the dismal 

results in published reports. Most institutions still tolerate defect or failure rates in 

hand hygiene of 40 percent or more—levels that would be considered shocking in 

any other industry69 (p. 274). 

Institution improvements should focus on process improvements that sustain best practices, using 

multifactorial approaches, and a commitment from the top administration through all levels of 

staff and employees to implement best practices.70

Proper Use of Personal Protective Equipment 

Infection control practices to reduce HAI include the use of protective barriers (e.g., gloves, 

gowns, face mask, protective eyewear, face shield) to reduce occupational transmission of 

organisms from the patient to the health care worker and from the health care worker to the 

patient. Personal protective equipment (PPE) is used by health care workers to protect their skin 

and mucous membranes of the eyes, nose, and mouth from exposure to blood or other potentially 

infectious body fluids or materials and to avoid parenteral contact. The Occupational Safety and 

Health Administration’s Bloodborne Pathogens Standard states that health care workers should 

receive education on the use of protective barriers to prevent occupational exposures, be able to 

identify work-related infection risks, and have access to PPE and vaccinations.71

Proper usage, wear, and removal of PPE are important to provide maximum protection to the 

health care worker. However, PPE may not be 100 percent protective, individual work practices 

may lead to exposure (e.g., needlestick injury), breaches in PPE might occur, and some breaches 

may go unrecognized. All PPE should be removed when leaving the patient care area.25 Gloves 

prevent gross contamination of the hands when touching body fluids, reduce the likelihood that 

microorganisms present on the hands of personnel will be transmitted to patients during invasive 

or other patient care procedures, and reduce the likelihood that hands of personnel contaminated 

with microorganisms from a patient or a fomite can transmit these microorganisms to another 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

patient. Gloves may have small, unapparent defects or may be torn during use, and hands can 

become contaminated during removal of gloves,72–75 thus hand hygiene is essential before 

donning another pair of gloves. 

Various types of masks, goggles, and face shields are worn alone or in combination to 

provide barrier protection. A surgical mask protects a patient against microorganisms from the 

wearer and protects the health care worker from large-particle droplet spatter that may be created 

from a splash-generating procedure. When a mask becomes wet from exhaled moist air, the 

resistance to airflow through the mask increases. This causes more airflow to pass around edges 

of the mask. The mask should be changed between patients, and if at anytime the mask becomes 

wet, it should be changed as soon as possible. Gowns are worn to prevent contamination of 

clothing and to protect the skin of health care personnel from blood and body fluid exposures. 

Gowns specially treated to make them impermeable to liquids, leg coverings, boots, or shoe 

covers provide greater protection to the skin when splashes or large quantities of potentially 

infective material are present or anticipated. Gowns are also worn during the care of patients 

infected with epidemiologically important microorganisms to reduce the opportunity for 

transmission of pathogens from patients or items in their environment to other patients or 

environments. When gowns are worn, they must be removed before leaving the patient care area 

and hand hygiene must be performed. 

Improper use and removal of PPE can have adverse health consequences to the health care 

worker. During the 2003 severe acute respiratory syndrome (SARS) outbreak in Canada, 44 

percent of the probable SARS cases were in health care workers. After institutional 

implementation of SARS-specific infection control precautions, 17 workers developed disease. 

Fifteen were interviewed to determine their knowledge and work practices that could have 

contributed to their infection. Only 9 (60 percent) reported they had received formal infection 

control training; 13 (87 percent) were unsure of the proper order in which to don and remove 

PPE; 6 (40 percent) reused items (e.g., stethoscopes, goggles, and cleaning equipment) elsewhere 

on the ward after initial use in the room of a SARS patient; and 8 (54 percent) were personally 

aware of a breach in infection control precautions. Fatigue and multiple consecutive shifts may 

have contributed to the transmission.76

From the experiences observed during the SARS outbreak, CDC developed training materials 

to increase the safety of the health care worker environment through improved use of PPE by 

health care personnel. Posters (bilingual), slides, and video information are available on the CDC 

Web site: http://www.cdc.gov/ncidod/dhqp/ppe.html. 

Consistent Evidence-Based Practices 

Professional organizations for infection control and health care epidemiology publish 

evidence-based guidelines regarding the practice of health care infection control, strategies for 

surveillance and prevention, and control of HAIs in U.S. health care facilities. These consensusbased scientific publications provide priority recommendations on the basis of the existing 

scientific data; theoretical rationale; and applicability of well-designed experimental, clinical, or 

epidemiologic studies to prevent HAIs in different patient care settings. Additionally, the Joint 

Commission’s initiative, Shared Visions—New Pathways 2004 accreditation process, focuses on 

continuous compliance with its standards, which contributes to health care organizations’ 

maintenance of safe, quality care and improved organizational performance.77 

Despite the high educational level of health care workers and knowledge of aseptic practices, 

adherence to published infection control precautions is not consistently applied.78 In one study, a 

12 
Preventing Health Care–Associated Infections

self-reported questionnaire demonstrated that although all health care providers knew the 

appropriate protective barrier equipment required for a particular patient care interaction, their 

reasons for nonadherence included perceived time constraints (64 percent), inconvenience (52 

percent), and presumption that the patient was not infected (34 percent).79 The observed rate of 

compliance was inversely related to the years of health care experience. 

Translation of evidence-based guidelines into clinical practice may require more than 

reliance on an individual practitioner’s knowledge and intentions. Organizational interventions 

may be necessary to better understand the barriers that impede the process of effectively 

reviewing and implementing evidenced-based practices into daily clinical practice.80–83 Standard 

policies and standards of practice should be time specific, measurable, and should also define the 

specific population of patients that will be affected. When the institution implements an 

evidence-based guideline that updates the current policy, a multidisciplinary intervention should 

be planned to ensure staff concurrence with the change; agreement that the new approach is 

crucial; an assurance that there will be adequate staff, knowledge, and resources to implement 

the change; and a method to evaluate the impact of the change.84

Antimicrobial-Resistance Campaign 

“In theory, there is no difference between theory and practice. But in practice, there is.” 

Jan L. A. van de Snepshceut, computer scientist and educator 

Background. After the first use of penicillin in the 1950s, antibiotic resistance developed 

rapidly in some bacteria such as Staphylococcus aureus. Over the last several decades, a shift in 

the etiology of more easily treated pathogens has increased toward more antimicrobial-resistant 

pathogens with fewer options for therapy. Infections from antimicrobial-resistant bacteria 

increase the cost of health care, cause higher morbidity and mortality, and lengthen hospital stays 

compared to infections from organisms susceptible to common, inexpensive antimicrobials. 

Antimicrobial resistance has continued to emerge as a significant hospital problem affecting 

patient outcomes by enhancing microbial virulence, causing a delay in the administration of 

effective antibiotic therapy, and limiting options for available therapeutic agents. In a 2003 

Institute of Medicine report, antimicrobial resistance was noted as a paramount microbial threat 

of the 21st century.85

Burden of organisms. Rates of antimicrobial resistance among hospital and community 

pathogens have increased considerably during the past decade. More than 70 percent of the 

bacteria that cause hospital-associated infections are resistant to at least one of the drugs most 

commonly used to treat these infections.86 According to 2003 National Nosocomial Infections 

Surveillance System data from ICU patients, 60 percent of Staphylococcus aureus isolates were 

resistant to methicillin, oxacillin, or nafcillin (MRSA)—an 11 percent increase from data 

reported the year before.87 There was a nearly 50-percent increase in nonsusceptible Klebsiella 

pneumoniae isolates to 3rd generation cephalosporins between 2002 and 2003. Although the rate 

of vancomycin-resistant enterococcus (VRE) has shown a less drastic increase than previous 

years, it still increased 12 percent in 2003 (for a total of 28.5 percent of all enterococci isolates). 

Another recent national survey of antimicrobial resistance trends and outbreak frequency was 

performed among U.S. hospitals (those hospitals having at least 50 beds, both general medical 

and surgical services, and accreditation by the Joint Commission) using the American Hospital 

Association annual survey data set.88 A total of 494 of the 670 hospital laboratories (74 percent) 

responded. Antimicrobial resistance rates were highest for oxacillin-resistant Staphylococcus 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

aureus (ORSA, also referred to as MRSA) (36 percent); two-thirds of the hospitals reported 

increasing MRSA rates, 4 percent reported decreasing rates, and 24 percent reported MRSA 

outbreaks. 

Mechanism of antibiotic resistance. The treatment of bacterial infections is not a 

straightforward process. Bacterial microorganisms are initially susceptible to a new antibiotic, 

but over time, as use of the antibiotic increases, new generations of the organism will selectively 

adapt by developing antibiotic resistance. These organisms have the ability to undergo protective 

spontaneous mutation within themselves or acquire an exogenous antibiotic-resistant gene 

through genetic transfer from another organism, which enables it to inactivate an antibiotic or 

nullify its killing activity. The human microbial population includes a combination of susceptible 

bacteria and antibiotic-resistant bacteria. Antimicrobial usage changes the competitive balance of 

the microbial population by decreasing the amount of susceptible bacteria, providing an 

opportunity for resistant bacteria to flourish. Areas within hospitals such as ICUs that have high 

rates of antimicrobial usage also have the highest rates of antimicrobial resistance. 

Patients can acquire an antibiotic-resistant organism through other mechanisms. Increased 

antibiotic treatments received in community settings can lead to the presence or colonization of 

antimicrobial-resistant organisms in the community population, which can be introduced into the 

hospital by patients on admission. These colonized organisms may not be detected if the patient 

is admitted for noninfectious reasons. This underscores the need for routine hand hygiene after 

all patient care, not just after care to patients on Contact Precautions. Often, it becomes apparent 

that silent transmission has occurred when the newly discovered presence of a resistant organism 

can be traced back to another patient who is later found to have been infected or colonized with 

the resistant organism. More frequently, however, the exact source of resistant organisms or the 

source of transmission within the institution remains undetermined. 

Prevention of antibiotic-resistant organisms. Authors of evidence-based guidelines on the 

increasing occurrence of multidrug-resistant organisms propose these interventions: stewardship 

of antimicrobial use, an active system of surveillance for patients with antimicrobial-resistant 

organisms, and an efficient infection control program to minimize secondary spread of 

resistance.89–91 Antimicrobial stewardship includes not only limiting the use of inappropriate 

agents, but also selecting the appropriate antibiotic, dosage, and duration of therapy to achieve 

optimal efficacy in managing infections. A prospective study on hospital mortality due to 

inadequate antimicrobial treatment demonstrated that the infection-related mortality rate for 

patients receiving inadequate antimicrobial treatment (42 percent) was significantly greater than 

the infection-related mortality rate of patients receiving adequate antimicrobial treatment (17.7 

percent) in a medical or surgical ICU setting.92

Earlier guideline recommendations by professional organizations were published between 

1995 and 1997 for the prevention of antimicrobial resistance in hospitals.93–95 To evaluate the 

application of the recommendations, a cross-sectional survey was performed to determine what 

types of antimicrobial-use programs were being used among 47 U.S. hospitals participating in 

the ICU component of the CDC’s National Nosocomial Infections Surveillance System.96 All 47 

hospitals had some established programs, although their practices did not meet all of the 

published recommendations. For example, one programmatic practice was to consult with an 

infectious disease physician or pharmacist (used 60–70 percent of the time) to discuss initial 

antimicrobial options; however, only 40 percent reported a system to measure compliance with 

administering the recommended antimicrobial agent. The Cochrane Collaboration reviewed 66 

published papers to develop “interventions to improve antibiotic prescribing practices for 

14 
Preventing Health Care–Associated Infections

hospital inpatients.”97 Interventions were aimed at varying outcomes (e.g., increase/decrease 

treatment, regimen, timing of dosing, restrictive or persuasive methods to reduce unnecessary 

antibiotic use). Studies showed that about half of the time, hospital physicians were not 

prescribing antibiotics properly. Nonetheless, most interventions demonstrated some 

improvement in antibiotic prescribing to reduce antimicrobial resistance or hospital-acquired 

infections. Hospital campaigns to prevent antimicrobial resistance include steps to (1) employ 

programs to prevent infections, (2) use strategies to diagnose and treat infections effectively, (3) 

operate and evaluate antimicrobial use guidelines (stop orders, restrictions, and criteria-based 

clinical practice guidelines), and (4) ensure infection control practices to reduce the likelihood of 

transmission.98 Nurse practitioners have a role as part of the health care team diagnosing and 

treating infections appropriately and should be familiar with strategies to improve antimicrobial 

use. All health care workers play a critical role in reducing the risk of transmission. 

Based on the factors contributing to antibiotic resistance in health care settings that were 

identified through data collection, guidelines, professional recommendations, and scientific 

research, the CDC compiled several tools in 2002 to increase awareness in health care settings. 

The Campaign to Prevent Antimicrobial Resistance in health care settings utilizes four strategies 

to increase awareness and encourage the best practices for antibiotic use and interventional 

programs to prevent resistance: prevent infection, diagnose and treat infection effectively, use 

antimicrobials wisely, and prevent transmission. Laminated cards, posters, slide sets, and fact 

sheets that can be used in a health care setting to promote recognition and utilization are listed at 

http://www.cdc.gov/drugresistance/healthcare/default.htm. A summary of the CDC’s 12-step 

program and specific nursing interventions is provided in Appendix 2. 

Summary of key concepts. A program that only scrutinizes and monitors antimicrobial use 

will not be effective to reduce antimicrobial resistance; it must also implement proper infection 

control measures and have laboratory, surveillance, and administrative support. The optimal 

strategy for control of antibiotic-resistant organisms is not the same for every health care facility 

as this individually depends on the levels of endemic colonization, presence of one or more 

resistant organisms, and levels of infection (low or outbreak levels). The ICP and hospital 

epidemiologist at each facility are valuable resources to provide programmatic education and 

recommend targeted infection control measures (e.g., use of personal protective barriers, hand 

hygiene resources, patient placement/segregation, and admission surveillance cultures). Similar 

to the example of antibiotic consultation practices and outcome measures, this plan will have 

little effect or opportunity to reduce the morbidity and mortality of infectious complications 

unless there is committed organizational support, including expert recommendations that are 

adopted into daily practice routines. Nursing personnel have the most patient contact and the 

most opportunity to interrupt the chain of transmission through adherence to consistent aseptic 

practices. 

Respiratory Hygiene and Cough Etiquette 

Respiratory viruses are easily disseminated in a closed setting such as a health care facility 

and can cause outbreaks that contribute to the morbidity of patients and health care staff. 

Personnel and patients with a respiratory illness commonly transmit viruses through droplet 

spread. Droplets are spread into the air during sneezing, talking, and coughing and can settle on 

surfaces. Transmission occurs by direct contact with mucous membranes or by touching a 

contaminated surface and self-inoculating mucous membranes. Respiratory viruses can 

sometimes have aerosol dissemination. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Precautions to prevent the transmission of all respiratory illnesses, including influenza, have 

been developed.99 The following infection control measures should be implemented at the first 

point of contact with a symptomatic or potentially infected person. Occupational health policies 

should be in place to guide management of symptomatic health care workers. 

1. Post visual alerts (in appropriate languages) at the entrance to outpatient facilities 

instructing patients and escorts (e.g., family, friends) to notify health care personnel of 

symptoms of a respiratory infection when they first register for care. 

2. Patients and health care staff should consistently practice the following: 

a. Cover the nose/mouth when coughing or sneezing. 

b. Use tissues to contain respiratory secretions and dispose of them in the nearest waste 

receptacle after use. 

c. Perform hand hygiene after having contact with respiratory secretions and 

contaminated objects or materials. 

3. During periods of increased respiratory infection activity in the community or yearround, offer masks to persons who are coughing. Either procedure masks (i.e., with ear 

loops) or surgical masks (i.e., with ties) may be used to contain respiratory secretions. 

Encourage coughing persons to sit at least 3 feet away from others in common waiting 

areas. 

4. Health care personnel should wear a surgical or procedure mask for close contact (and 

gloves as needed) when examining a patient with symptoms of a respiratory infection. 

Maintain precautions unless it is determined that the cause of symptoms is not an 

infectious agent (e.g., allergies). 

Evaluation 

The ICP or a nurse on a specific patient care unit should design a periodic evaluation 

program of infection control practices, including aseptic technique practices. Evaluation methods 

include a self-assessment survey of intended practices, direct observational assessments by 

another health care worker or a patient, and self-completion of checklists that review work 

practices and identify opportunities for improvement within the health care operations. If 

deficiencies or problems in the implementation of standardized infection control procedures are 

identified, further evaluation activities (e.g., root-cause analysis) may be indicated to identify and 

rectify the contributing factors to the problem.100

Most evaluation reviews are generated after a major, life-threatening error occurs, which 

usually happens infrequently. Historically, when an evaluation determined that a process 

completed by personnel was deficient, problem-solving efforts focused on the identification of 

the specific individual(s) who “caused” the problem. Later, quality improvement efforts focused 

on developing a culture of safety and recognized that additional contributions to errors were due 

to complex, poorly designed systems. The advantage of an evaluation that reviews system 

problems is that it encourages health care professionals to report adverse events and near misses 

that might be preventable in the future, while balancing the identification of system problems 

with holding individual providers responsible for their everyday practices. Improvement is 

impossible without evaluation reports to provide data on the factors that contribute to mistakes 

and lead to subsequent individual and system changes that support safer practices.101

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An evaluation strategy examining process measures include the following examples: 

• Document staff use of maximum sterile barriers (cap, mask, sterile gown, sterile gloves, 

large sterile sheet) and aseptic technique for the insertion of central intravenous catheters 

or guidewire exchange. 

• Document timing of antibiotic prophylaxis when used in surgical patients (e.g., within 1 

hour of incision). 

• Document if hand hygiene is performed and clean or sterile gloves are worn before 

assessing a catheter insertion site or changing a dressing on intravascular catheters. 

• Document time elapsed from when patient culture (microbiology and susceptibility) 

results are reported and when the appropriate isolation precautions are instituted (patient 

room placement, signs, PPE used, disposable equipment used, medical record 

documentation, etc.). 

• Ensure that staff (nurses, doctors, and housekeeping) enter a contact isolation room using 

the specified personal protective barriers (e.g., gloves, gown) on each entry. 

• Ensure that staff properly remove PPE after leaving a patient’s room. 

• Assess the annual rates of influenza vaccination for health care workers and other 

personnel eligible to receive vaccination; assess the rates of influenza vaccination for 

patients. 

• Ensure that needle disposal containers are no more than three-quarters full at time of 

disposal. 

• Periodically monitor and record adherence with the hand hygiene guidelines: the number 

of times personnel washed their hands divided by the number of hand-hygiene 

opportunities, computed by ward or by service. Provide feedback to personnel regarding 

their performance. 

• Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or 

hand antisepsis) used per 1,000 patient days. 

• When outbreaks of infection occur, assess the adequacy of health care worker hand 

hygiene. 

• When a patient with a known colonization or infection with a multidrug-resistant 

organism (e.g., MRSA, VRE) is transferred to your facility, evaluate effectiveness of 

system notification to health care personnel in the receiving facility. 

• Record compliance with hospital policy for catheter-site dressing changes. 

Research Implications*

1. Research and apply behavioral and management sciences to achieve implementation of 

evidence-based clinical guidelines and compliance with infection prevention policies. 

2. Develop methods to improve the appropriateness of antimicrobial use based on identified 

antimicrobial control measures and institution microbial susceptibility patterns. 

3. Collect data for the economic impact of HAIs and other adverse effects and resulting return 

of investment for prevention methods. 

4. Identify specific components of infection prevention and control programs and staffing in 

health care institutions that are effective (and cost effective) in reducing rates of infection. 

 

*

 Adapted from Lynch et al. 2001104 and Aboelela et al. 2006.105

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

5. Improve health care institution information systems for seamless review of appropriateness 

of infection control-related care based on patient diagnosis. 

6. Determine standard indices for measurement of effectiveness and cost of infection control 

measures. 

7. Measure effect of staffing changes (reduced personnel, prolonged work hours, varying levels 

of formal education) on patient outcomes related to infectious outcomes of morbidity and 

mortality (e.g., colonization of microorganisms, postoperative wound infections, and 

catheter-related infections). 

8. Design studies so that independent effects of specific interventions can be identified. 

9. Monitor the implementation of interventions in a multicenter study to examine a cause-andeffect response and differentiate between efficacy and effectiveness. 

10. Develop interdisciplinary research teams to improve the rigor and sophistication of studies 

conducted. 

Conclusions 

It is the responsibility of all health care providers to enact principles of care to prevent health 

care–associated infections, though not all infections can be prevented. Certain patient risk factors 

such as advanced age, underlying disease and severity of illness, and sometimes the immune 

status are not modifiable and directly contribute to a patient’s risk of infection. Depending on the 

patient’s susceptibility, a patient can develop an infection due to the emergence of their own 

endogenous organisms or by cross-contamination in the health care setting. Benefits of 

antimicrobial therapy will alter the microbial flora by reducing one microbial presence but may 

allow the emergence of another, causing a new infection (e.g., antibiotic-associated diarrhea). 

Nurses can reduce the risk for infection and colonization using evidence-based aseptic work 

practices that diminish the entry of endogenous or exogenous organisms via invasive medical 

devices. Proper use of personal protective barriers and proper hand hygiene is paramount to 

reducing the risk of exogenous transmission to a susceptible patient. For example, 

microorganisms have been found in the environment surrounding a patient and on portable 

medical equipment used in the room. Environmental surfaces around a patient infected or 

colonized with a multidrug-resistant organism can also become contaminated. Health care 

workers should be aware that they can pick up environmental contamination of microorganisms 

on hands or gloves, even without performing direct patient care. Proper use and removal of PPE 

followed by hand hygiene will reduce the transient microbial load that can be transmitted to self 

or to others. Identified aseptic and infection control practices have been proven to reduce the 

dissemination of organisms to a single patient, to prevent repeated transmissions that contribute 

to an outbreak situation among multiple patients, or to become established in the health care 

environment as endemic hospital flora. 

Nursing has many complicated scopes of practice, which challenge time management, 

priority setting, and efficiency of practice. Although system and administrative support is 

beneficial to supporting aspects of nursing care, direct care is performed by individuals. Every 

individual nurse focuses on making a difference throughout the daily workloads and enormous 

responsibilities but changes in a patient’s medical condition can become overwhelming. One 

nurse comes to mind who found the resolve to make significant strides within the patient ward 

dealing with chronically overwhelming situations. She was administratively responsible for 

18 
Preventing Health Care–Associated Infections

directing and addressing the challenges of all patients’ chronic wound infections, ongoing crosscontamination, lack of needed medical supplies and equipment, severe understaffing, working 

extra shifts, and still finding time to provide care and comfort to patients. By her personal efforts 

to improve wound care, aseptic practices, and hand hygiene among all nursing and medical staff, 

mortality dropped in a dramatic decline from 33 percent to 2 percent within a 9-month period.102

These sustained and dedicated efforts to reduce patient infections and improve patient care in 

light of overwhelming adversity set a standard of practice for all nurses to follow. That nurse was 

Florence Nightingale, defining the art of nursing in the 1850s. Although medical care is more 

advanced and technically more complex since that time, it was the dedication of a nurse (like you) 

to ensure aseptic practices despite the significant nursing demands of patient care that makes the 

difference for the patients—then and now. 

National surveys of the public have repeatedly found nursing to be one of the most trusted 

professions. The public trusts us to provide safe care and employ best practices by following 

certain principles: (1) to not work while having an infectious illness, (2) to be knowledgeable 

about the methods to protect our patients from transmission of disease, (3) to perform aseptic 

practice and monitor patient infections, (4) to participate in quality improvement initiatives to 

reduce infections, and (5) to provide care even if it means self-risk from infection. As nurses we 

have an ethical obligation to meet that trust and uphold the highest standards for our patients and 

the public, whether we are providing direct care, teaching about proper health care, or overseeing 

nursing practice.103 

It has been demonstrated that nursing and medical practices can pick up transient 

microorganisms from intact patient skin and from environmental surfaces. Although the amount 

of contamination is not quantified and the exact incidence is not apparent, it does occur. Hand 

hygiene and aseptic practices before caring for a susceptible patient can reduce the transient 

carriage and transfer of microorganisms. The protective benefits of infection control using 

evidence-based practices are cost effective and numerous: they not only contribute to the best 

individual patient care outcome, but also protect health care workers, increase public awareness 

in all health care settings about infection control issues, and maintain the highest standards in 

nursing, which positively contributes to our goal for the best possible patient and public health 

outcomes. 

Author Affiliation 

Amy S. Collins, B.S., B.S.N., M.P.H., Centers for Disease Control and Prevention; Atlanta, 

Georgia. E-mail: acollins@cdc.gov. 

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Control 2006 Oct; 34(8):484-94. 

24 
Preventing Health Care–Associated Infections

Appendix 1. Resources 

Federal Agencies 

Agency for Healthcare Research and Quality 

Measuring health care quality, outcomes, and effectiveness, etc. 

http://www.ahrq.gov/ 

Centers for Disease Control and Prevention: CDC for Healthcare Providers 

Health care infections, hepatitis, antimicrobial resistance, health care worker protection. Slide 

presentations. Fact sheets. http://www.cdc.gov/CDCForYou/healthcare_providers.html 

Guidelines http://www.cdc.gov/ncidod/dhqp 

Prevention of Catheter-Associated Urinary Tract Infections, 1981 

Environmental Infection Control in Healthcare Facilities, 2003 

Hand Hygiene in Healthcare Settings, 2002 

Preventing Healthcare-Associated Pneumonia, 2003 

Guidelines for Infection Control in Health Care Personnel, 1998 

Infection Prevention and Control in the Long-Term Care Facility, 1997 

Guideline for Isolation Precautions in Hospitals, 1996 

Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002 

Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 

Guideline for Prevention of Surgical-Site Infection, 1999 

Public Health Service Guidelines on the Management of Exposure to HBV, HCV, and 

HIV with PEP Recommendations, 2001 

Updated U.S. Public Health Service Guidelines for the Management of Occupational 

Exposures to HIV and Recommendations for Post-Exposure Prophylaxis, 2005 

Guidelines for Preventing the Transmission of M. tuberculosis in Health Care Settings, 

2005 

Food and Drug Administration 

Information for Health Professionals (Medical Devices, Drugs, etc.) 

http://www.fda.gov/oc/oha/default.htm 

U.S. Department of Health and Human Services 

Pandemic Flu.

http://pandemicflu.gov/ 

National Institutes of Health: National Institute of Allergy and Infectious Diseases 

Health, science, research, research funding, news. 

http://www3.niaid.nih.gov/ 

Occupational Safety and Health Administration 

Hospital eTool (health care hazards, infection, housekeeping, nursing homes) 

http://www.osha.gov/SLTC/etools/hospital/hazards/infection/infection.html 

25 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Professional Organizations

American Nurses Association 

Center for Occupational and Environmental Health 

Occupational health, RNno harm, influenza posters, safe needles. 

http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental.aspx 

Association for Professionals in Infection Control and Epidemiology 

Educational brochures, assorted topics; Protect Our Patients Campaign. 

http://www.apic.org/Content/NavigationMenu/Education/EducationResources/Educational_Broc

hur.htm 

Community-associated MRSA references.

http://www.apic.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&

ContentFileID=5801 

Joint Commission (Joint Commission on Accreditation of Healthcare Organizations) 

Infection control initiatives, standards. 

http://www.jointcommission.org/PatientSafety/InfectionControl/ 

National Quality Forum 

Health care quality and reporting. 

http://www.qualityforum.org/ 

Society for Healthcare Epidemiology of America (SHEA) 

Guidelines, outbreak resources, drug-resistant organisms. 

http://www.shea-online.org/index.cfm 

Journals, Articles 

MedlinePlus Infection Control (National Library of Medicine)

http://www.nlm.nih.gov/medlineplus/infectioncontrol.html 

Infection Control and Hospital Epidemiology online journal (SHEA)

http://www.journals.uchicago.edu/ICHE/home.html 

American Journal of Infection Control online journal (APIC)

http://www.apic.org/Content/NavigationMenu/Publications/AJIC/AJIC.htm 

Hand Hygiene Resources

Centers for Disease Control and Prevention 

Posters, brochures, media kit. 

http://www.cdc.gov/handhygiene/default.htm 

26 
Preventing Health Care–Associated Infections

Institute for Healthcare Improvement 

Improving Hand Hygiene. A Guide for Improving Practices among Healthcare Workers.

http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuideImprovingHandHy

giene.htm 

World Health Organization 

Guidelines on Hand Hygiene in Healthcare. Advanced draft available. 

http://www.who.int/patientsafety/information_centre/documents/en/index.html 

U.S. Department of Veterans Affairs 

Infection—Don’t Pass It On (posters, stickers, buttons).

http://www.publichealth.va.gov/InfectionDontPassItOn/Default.htm 

27 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Appendix 2. Campaign To Prevent Antimicrobial 

Resistance in Health Care Settings 

Centers for Disease Control and Prevention 

Adapted from information on http://www.cdc.gov/drugresistance/healthcare/default.htm 

Strategy Steps Related Fact Nursing Actions 

Prevent Infection 1. Influenza and 

Pneumococcal 

vaccinations 

Predischarge 

immunizations of at-risk 

hospital patients and 

health care personnel will 

prevent infections. 

♦ Give influenza and pneumococcal 

vaccine to at-risk patients before 

discharge. 

♦ Receive annual influenza 

vaccinations. 

2. Get the catheter out Catheters and other 

invasive devices are the 

# 1 exogenous cause of 

hospital-onset infections. 

Use catheters— 

♦ Only when essential. 

♦ With proper insertion and care 

protocols. 

♦ Only as long as needed. 

Diagnose and 

Treat Infection 

Appropriately 

3. Target the pathogen Appropriate therapy 

(correct regimen, timing, 

dosage, route, and 

duration) saves lives. 

♦ Culture the patient. 

♦ Verify empiric therapy is to a likely 

pathogen and definitive therapy is 

treating a known pathogen. 

4. Access the experts Infectious disease expert 

collaboration improves 

the outcome of serious 

infections. 

Incorporate guidance from infectious 

disease experts into daily care plan. All 

full-time, part-time, and contract staff 

should know and utilize 

recommendations. 

Use 

Antimicrobials 

Wisely 

5. Practice antimicrobial 

control 

Programs to improve 

antibiotic use are 

effective. 

Know your pharmacy policies on 

ordering, restrictions, switching, and 

stopping. Utilize or develop online 

ordering with computerized decision 

support/rationale. 

6. Use local data The prevalence of 

resistance can vary by 

time, locale, patient 

population, hospital unit, 

and length of stay. 

Know the common organisms in your 

clinical area and the effective 

antibiotics used to treat each infection. 

7. Treat infection, not 

contamination 

A major cause of 

antimicrobial overuse is 

“treatment” based on 

results of patient cultures 

that become 

contaminated. 

Utilize proper protocols to collect 

patient blood and other specimens for 

culture. Submit to laboratory in proper 

medium/collection containers and 

within the recommended time. 

8. Treat infection, not 

colonization 

A major cause of 

antimicrobial overuse is 

“treatment” based on 

colonization. 

Be familiar with practice guidelines for 

clinical assessments of new symptoms 

(i.e., fever) in critically ill patients and 

when cultures are warranted. 

9. Know when to say 

“no” to vanco 

Vancomycin overuse 

promotes emergence, 

selection, and spread of 

resistant pathogens. 

Be familiar with hospital policy on 

proper vancomycin utilization and 

when it should be discouraged (e.g., 

routine surgical prophylaxis and the 

exceptions, etc.). 

28 
Preventing Health Care–Associated Infections

Strategy Steps Related Fact Nursing Actions 

10. Stop antimicrobial 

treatment 

Failure to stop 

unnecessary 

antimicrobial treatment 

contributes to overuse 

and resistance. 

Be aware of the patient’s infection 

status and need for an antibiotic. Stop 

or don’t use antibiotics when 

♦ The infection is cured; 

♦ Cultures are negative and infection 

is unlikely; and 

♦ Infection is not diagnosed. 

Prevent 

Transmission 

11. Isolate the pathogen Patient-to-patient spread 

of microorganisms can be 

prevented. 

Practice strict aseptic technique to 

prevent transmission of organisms. 

Strict oversight of proper contact 

precautions when used and proper 

room disinfection. 

12. Break the chain of 

contagion 

Health care personnel 

can spread antimicrobialresistant pathogens from 

patient to patient. 

Clean hands can pick up and transfer 

microorganisms. Hand hygiene is 

essential─set an example for others. 

29