Protocols and Procedures

Once a facility has developed a basic infection surveillance program, it must establish protocols and timetables to define the frequency and extent of the control measures. For example, there must be a written protocol detailing the steps involved in cleaning an operating room each time it is used. This protocol is best structured as a checklist to facilitate documentation of the cleaning process, thus serving both as a guide for someone who may be new to the job and as a written record of the cleaning process. The infection control committee should periodically review the completed checklists to ensure that they are properly filled out

The infection control committee should also establish a comprehensive system for labeling potential infection risks. This includes isolation of infected patients, clear identification of specimens that pose an infection hazard, proper disposal of contaminated bedclothes, and so on. Such a system will reduce the chance of infecting a staff member or having a staff member unintentionally infect another patient.

The member of the medical staff have the most important role in the control of hospital infection. A physician must not admit a patient with a contagious disease without alerting the infection control personnel and arranging for proper isolation. This procedure should be part of the bylaws and medical section rules. Each violation of the procedure must be investigated. A persistent pattern of improper admissions of contagious patients should be grounds for loss of staff privilege.

Once the patient is in the hospital, the physician must exercise great care to avoid spreading the infection to other persons. This demands attention to such mundane tasks as hand-washing and the cleaning of diagnostic instructions. The nursing staff must observe the isolation protocol and must insist that the physicians do the same. There should also be a mechanism whereby a nurse or another physician can require the infection control committee to review the treatment a patient is receiving. Further, the hospital may demand that specimens be obtained for laboratory analysis before antibiotic therapy is begun (once antibiotics are given, it may be difficult to identify the infectious organism).

The major sources of data that the infection control and antibiotic review committees must interpret are the reports of culture results and the pharmacy records of antibiotic administration. Since even a small practice or hospital will generate a large number of antibiotic prescriptions and lab reports, the processing of these reports must be automated. The review committees will need to establish criteria for flagging data and trends that require committee action.