Infection Control Policies and Hospital-Associated Infections Among
Surgical Patients: Variability and Associations in a Multicenter
Pediatric Setting
Danielle M. Zerr, MD, MPH*‡; Michelle M. Garrison, MPH§; Amanda L. Allpress, BA‡; Joan Heath, RN, BSN, CIC‡; and Dimitri A. Christakis, MD, MPH*‡§
ABSTRACT. Background. Hospital-associated infec-tions are an important cause of patient morbidity and death. Little is known about the variability of infection rates and infection control practices among pediatric hos-pitals.
Methods. This cross-sectional study was performed with the Pediatric Health Information System database, which includes demographic and diagnostic data for 35 freestanding, noncompeting, children’s hospitals, and with data from a survey of the hospitals, which yielded additional information on infection control policies and practices. Patients undergoing elective surgical proce-dures were included in this study.
Results. Of the 35 eligible hospitals, 31 (89%) chose to participate in the survey component of this study. A total of 48 278 patients met the inclusion criteria for the study; 2.3% of these patients had respiratory infections and 0.8% had gastrointestinal infections. The frequency of patients diagnosed with respiratory or gastrointestinal infections varied considerably among the hospitals and ranged from <1% to 6%. Certain infection control pro-cesses also varied among the hospitals during the study period. For instance, of the 31 hospitals, 12 monitored hand hygiene, 19 had administrative support of hand hygiene, and 16 had alcohol hand gel present for the entire study period. The presence of alcohol hand gel for the entire study was strongly and independently associ-ated with lower odds of gastrointestinal infections (ad-justed odds ratio: 0.64; 95% confidence interval: 0.49-0.85).
Conclusions. Hospitals should support the use of al-cohol hand gel, with the aim of decreasing hospital-associated infection rates.Pediatrics 2005;115:e387–e392. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2004-2014;
infection control, hospital-associated infection, hand hy-giene.
ABBREVIATIONS. ICD-9, International Classification of Diseases, Ninth Revision; PHIS, Pediatric Health Information System; OR, odds ratio; CI, confidence interval; CDC, Centers for Disease Control and Prevention.
H
ospital-associated infections represent a seri-ous and growing health problem.1,2 The Centers for Disease Control and Prevention (CDC) estimates that ⬃2 million people acquire hospital-associated infections each year and that⬃90 000 of these patients die as a result of their infections. A variety of hospital-based strategies aimed at preventing such infections have been pro-posed, and some have been tested. On the basis of such data and expert opinion, the CDC has devel-oped and regularly updates specific guidelines aimed at preventing the transmission of pathogens within the hospital setting.3 An important compo-nent of these guidelines involves hand hygiene.4
How broadly these recommendations have been implemented in pediatric hospitals is not known. Moreover, despite the quantity of data supporting the use of infection control measures to prevent hos-pital-associated infections, there have been few mul-ticenter studies examining the variability of infection rates and infection control policies among institu-tions and investigating which infection control mea-sures might be more important, especially in pediat-ric settings. Therefore, we conducted this study with 3 objectives, ie, (1) to describe the variation in the infection control practices in a large diverse sample of children’s hospitals, (2) to describe the variation in the rates of hospital-associated infections in these institutions, and (3) to determine which infection control policies were associated with lower rates of hospital-associated infections.
METHODS Data Source
We used the Pediatric Health Information System (PHIS) data-base developed by the Child Health Corporation of America, which includes demographic and diagnostic data on 35 freestand-ing, noncompetfreestand-ing, children’s hospitals. The database includes diagnoses in theInternational Classification of Diseases, Ninth Revi-sion(ICD-9) format. We used data collected for hospitalizations with discharges occurring from October 1, 2001, through Septem-ber 30, 2003.
We supplemented these data with a survey of the hospitals to obtain additional information on infection control policies and practices. One investigator (J.H.), who was blinded to the hospital-specific infection rates, administered a standardized questionnaire to infection control practitioners at each hospital. Questions in-volved 5 different domains, ie, (1) hospital infection control prac-titioners and physician support, (2) visitor screening policies, (3) hand hygiene policies and resources, (4) staff access to ethanol hand gel, and (5) viral testing and cohort practices. Questions about viral testing and cohort practices included questions specific From the *Department of Pediatrics and §Child Health Institute, University
of Washington, Seattle, Washington; and ‡Children’s Hospital and Regional Medical Center, Seattle, Washington.
Accepted for publication Nov 15, 2004. doi:10.1542/peds.2004-2014
No conflict of interest declared.
Address correspondence to Danielle M. Zerr, MD, MPH, Children’s Hos-pital and Regional Medical Center, 8G-1, 4800 Sand Point Way NE, Seattle, WA 98105. E-mail: zerr@u.washington.edu
to both respiratory and gastrointestinal infections. The study pro-tocol was reviewed and approved by the Children’s Hospital and Regional Medical Center institutional review board.
Patients
Our study included pediatric patients (through age 18) with discharge dates between October 1, 2001, and September 30, 2003. Because the PHIS database does not include dates of medical diagnoses, we could not use relative dates of medical diagnoses and procedures to determine hospital-associated infections. In-stead, we restricted the analysis to patients hospitalized for pro-cedures that were considered highly likely to have been elective or semielective, under the hypothesis that these patients were least likely to have been admitted with preexisting respiratory or gas-trointestinal infections, because elective procedures are typically postponed in the presence of an intercurrent illness. In determin-ing which patients met these criteria, we began with a list of the most commonly performed, primary surgical procedures in the pediatric hospital setting, and clinicians ascertained by consensus which of these would be considered both an elective procedure and the primary reason for admission in the majority of cases (the list of included procedures and their associated ICD-9 procedure codes is available upon request and includes, for example, tonsil-lectomies, shunt revisions, hypospadias repairs, and repairs of atrial and ventricular septa). The PHIS database identifies a pri-mary procedure for each patient who has any procedures coded, and these results were matched against our list of included pro-cedures to determine study inclusion. Approximately 80% of these patients underwent their primary procedures within the first 24 hours after admission. If an individual met the study criteria more than once during the time period, then only the first hospitaliza-tion was included in the analysis. In addihospitaliza-tion, only patients from hospitals that participated in the survey could be included in the analysis.
Outcomes
The outcomes we evaluated were hospital-associated respira-tory and gastrointestinal infections, defined by the presence of a diagnostic code for an acute respiratory (ICD-9 code 079.6x, 460 – 462.xx, 464 – 466.xx, or 480 – 487.xx) or gastrointestinal (ICD-9 code 001.xx– 009.xx or 787.91) infection at discharge. For the purposes of the study, we assumed that these infections were the result of hospital transmission, given the elective nature of the admission.
Statistical Analyses
Descriptive analyses and logistic regressions were performed, evaluating respiratory and gastrointestinal infection outcomes separately. We chose not to combine these into a single outcome measure because we hypothesized that there could be differences in the factors associated significantly with each, given the differ-ences in the causative pathogens and the associated differdiffer-ences in modes of transmission. The predictors of interest were derived from the survey. Additional covariates were also evaluated and included age category (⬍1, 1–2, or⬎2 years), gender, Medicaid status, month of admission, hospital bed size, coded medical or surgical complications, comorbid diagnoses (including cancer, di-abetes mellitus, immunodeficiencies, sickle cell anemia, cardiovas-cular disorders, asthma, inflammatory bowel disease, autoim-mune rheumatologic disorders, craniofacial disorders, burns, and disorders of prematurity), and type of elective surgical procedure performed (neurologic, ophthalmologic, otorhinolaryngologic, cardiologic, genitourinary, orthopedic, or involving cutaneous tis-sue). Logistic regression analyses were used to evaluate associa-tions between individual predictors of interest and outcomes, with adjustment for the covariates listed above. We then manually built forward, stepwise, multivariate (ie, multiple predictors of inter-est), regression models that examined which of the predictors of interest had the greatest impact on infection, with control for the
TABLE 1. Demographic and Clinical Characteristics of All Included Patients Who Underwent Elective Surgery and the Subset of Those Who Developed Respiratory and/or Gastrointestinal Infections
Overall Range Across Hospitals Respiratory Infections Gastrointestinal Infections
Sample size 48 278 443–3429 1095 392
Male, % 59 53–84 59 55
Mean age, y (SD) 5.4 (5.4) 1.9–6.6 4.3 (5.1) 4.3 (5.2)
Age group, %
⬍1 y 26 15–72 33 35
1–2 y 19 8–25 25 24
⬎2 y 55 20–68 42 41
Medicaid status, % 35 15–64 40 46
Surgery type, %
Cardiologic 14 0–20 20 15
Genitourinary 9 1–63 3 2
Neurologic 14 3–28 16 9
Ophthalmologic ⬍1 0–1 ⬍1 ⬍1
Orthopedic 5 2–12 2 5
Otorhinolaryngologic 26 13–43 27 10
Skin and soft tissues 30 8–46 31 56
Comorbid diagnoses, %
Asthma 4 1–10 10 5
Burns 3 0–21 3 3
Cancer 5 2–10 9 21
Cardiovascular disorders 20 5–38 39 31
Craniofacial disorders 8 2–18 3 2
Diabetes mellitus 1 0–1 ⬍1 1
Immunodeficiencies 1 0–1 3 3
Inflammatory bowel disease ⬍1 0 to⬍1 ⬍1 1
Rheumatologic disorders ⬍1 0–1 ⬍1 1
Sickle cell anemia 1 0–3 1 1
Disorders of prematurity 3 0–21 3 ⬍1
Complications, %
Surgical 24 10–37 44 46
Medical ⬍1 0–1 2 3
Hospital stay
Mean length of stay, d (SD) 5.7 (11.3) 3.3–8.9 20.5 (29.1) 23.2 (31.5)
Mean stay before surgery, d 1.6 (5.5) 0.6–3.9 6.2 (15.1) 6.5 (17.4)
No. of beds at hospital 309 (138) 140–750 327 (163) 306 (139)
covariates. ThePvalues for the odds ratios (ORs) for the predic-tors of interest from univariate logistic regression analyses deter-mined the order in which predictors of interest were added to the multivariate models. Predictors of interest withPvalues of⬍.25 were allowed to remain in the final multivariate model.
The regression analyses were clustered with respect to hospital, to account for the decreased variability within hospitals, com-pared with between hospitals.5,6To protect the anonymity of the
participating hospitals, all results are presented with the hospitals not identified. All analyses were conducted with Stata 8.0 software (Stata Corp, College Station, TX).
RESULTS
A total of 48 278 patients met the inclusion criteria for the study. Overall, 59% of the included patients were male, 45% wereⱕ2 years of age, and 35% were recipients of Medicaid (Table 1). Of the 48 278 pa-tients, 2.3% had respiratory infections and 0.8% had gastrointestinal infections. Among the 1487 patients with infections, 51 (3%) had both respiratory and gastrointestinal infections. Among the respiratory in-fections, 45% were pneumonia, 9% were bronchioli-tis or respiratory syncytial virus, 14% were croup, tracheitis, laryngitis, or epiglottitis, and 25% were an upper respiratory infection not otherwise specified. Among the gastrointestinal infections, 51% were di-arrhea not otherwise specified, 24% wereClostridium difficile, and 10% were rotavirus. The frequency of patients being diagnosed with respiratory or gastro-intestinal infections varied considerably among the hospitals, ranging from almost 1% to 6% (Fig 1); this variation was statistically significant (P ⬍ .001). Compared with patients without infections, patients with respiratory and gastrointestinal infections were younger, more likely to receive Medicaid, more
likely to have a comorbid diagnosis, and more likely to have experienced a medical or surgical complica-tion and had longer lengths of stay (both total and before surgery) (2 test, P values all ⬍.05; data not shown) (Table 1).
Of the 35 eligible hospitals, 31 (89%) chose to par-ticipate in the survey component of this study. The mean number of infection control practitioners per 100 beds was 0.71 (SD: 0.26), and 30 of the 31 insti-tutions queried had infectious disease physician sup-port (Table 2). Most institutions isolated patients with respiratory (n⫽30) or gastrointestinal (n⫽29) symptoms, performed surveillance for respiratory (n⫽27) and gastrointestinal (n⫽23) infections, used personal protective equipment with these patients (n ⫽ 29 and 28, respectively), and performed viral testing for patients with such symptoms (n⫽26 and 25, respectively), whereas relatively few centers co-hort-assigned symptomatic patients to staff members (n⫽8 and 5, respectively). More variability was seen regarding policies on visitor screening for communi-cable illnesses and hand hygiene monitoring and support. Twenty-one institutions had a policy to screen all visitors, whereas 5 had a policy to screen children only and 5 had no policy. Of the 26 institu-tions that screened visitors, the policies of 25 called for restricting visitation of those who screened posi-tive for communicable illness. Only 12 institutions monitored hand hygiene practices, whereas 19 re-ceived administrative resources and support for hand hygiene-related efforts. Alcohol hand gel was available during the study period in all except 2
institutions but was present for the entire study in only 16.
After adjustment for covariates, the presence of alcohol hand gel for the entire study was strongly associated with decreased risk of hospital-associated gastrointestinal infections (adjusted OR: 0.66; 95% confidence interval [CI]: 0.49 – 0.88;P⬍.01) (Table 3). The addition of other infection control variables (in-cluding those in Table 2) to the model in(in-cluding the presence of alcohol hand gel for the entire study and covariates did not change the relationship between the presence of gel and hospital-associated gastroin-testinal infections or improve the overall significance of the model. There were no predictors of interest that were associated with respiratory infections after adjustment for covariates.
DISCUSSION
This multicenter study of 31 freestanding pediatric centers yielded novel findings regarding infection control practices and hospital-associated infections. We found that (1) the frequency of hospital-associ-ated gastrointestinal and respiratory infections among patients undergoing elective surgical proce-dures varied considerably among hospitals, (2) infec-tion control practices varied among hospitals, and (3) the presence of alcohol hand gel for the entire period of the study was strongly and independently associ-ated with decreased risk of hospital-associassoci-ated gas-trointestinal infections among patients undergoing elective surgical procedures.
The importance of infection control programs in
TABLE 2. Infection Control Policies and Practices
Hospitals (n⫽31)
Patients (n⫽48 278), %
Hospital information
Mean no. of ICPs per 100 beds (SD) 0.73 (0.26)
ICP in professional organization 31 100
ICP certified 29 96
ICPs participate in continuing education 31 100
Full-time equivalent of physician support (SD) 0.20 (0.27)
Physician trained in infectious diseases 30 98
Physician trained in epidemiology 22 76
Condition-specific practices regarding viral testing, surveillance, isolation, use of PPE, and cohort assignment
Viral testing*
Respiratory 26 84
Gastrointestinal 25 73
Surveillance†
Respiratory 27 88
Gastrointestinal 23 73
Isolation of symptomatic patients‡
Respiratory 30 97
Gastrointestinal 29 92
Use of PPE§
Respiratory 29 95
Gastrointestinal 28 91
Cohort储
Respiratory 8 28
Gastrointestinal 5 19
Policies on visitation and visitor screening/restriction for communicable illness
No policy for screening visitors for illness 5 13
Policy for screening/restricting children only¶ 5 15
Policy for screening/restricting all visitors¶ 21 71
Hand hygiene monitoring, support, and education
Signs reminding staff members and visitors to clean hands 26 84
Hand hygiene monitored or observed 12 36
Administrative support for improving hand hygiene 19 62
Communication resources for hand hygiene education 21 65
Parent education regarding hand hygiene 24 84
Alcohol hand gel
Any availability of gel for any portion of the study period 29 95
Gel available in multiple locations 22 73
Gel available for the entire study period 16 54
Infection control policies and practices are expressed on the hospital level as the number of hospitals with the specific policy or practice or the mean (SD) for continuous variables and from the patient perspective as the percentage of patients in a setting where the policy or practice was in place. ICP indicates infection control practitioner; PPE, personal protective equipment.
* Viral testing was typically performed for patients experiencing respiratory or gastrointestinal symptoms. † The institution tracked hospital-associated respiratory and gastrointestinal infections.
‡ The institution had a policy to isolate patients (in single rooms or in multibed rooms with patients with the same diagnosis) experiencing respiratory or gastrointestinal symptoms.
§ The institution had a policy regarding personal protective equipment worn by staff members caring for patients with respiratory or gastrointestinal infections.
储The institution had a policy regarding cohort assignment of staff members to patients with respiratory or gastrointestinal symptoms during the period of study.
decreasing hospital-associated infections is well rec-ognized. The Joint Commission on Accreditation of Healthcare Organizations created accreditation stan-dards for infection control in 1976, providing addi-tional stimulus for hospitals to supply administrative and financial support for infection control. The CDC-initiated Study on the Efficacy of Nosocomial Infec-tion Control in the 1970s and 1980s identified 4 in-fection control components important in reducing hospital-associated infection rates.7 The 4 elements included the presence of (1) a trained, effectual, in-fection control physician, (2) an inin-fection control practitioner for every 250 beds, (3) organized surveil-lance and control mechanisms, and (4) a system for reporting infection rates to practicing surgeons. Al-though we could not duplicate the complexity of the Study on the Efficacy of Nosocomial Infection Con-trol to confirm this, most if not all of the hospitals involved in our study likely met these basic criteria, given current Joint Commission on Accreditation of Healthcare Organizations standards8 and the infor-mation from the questionnaire demonstrating infec-tious disease physician involvement in infection con-trol, relatively large numbers of infection control practitioners, and evidence of organized surveillance and control activities. The fact that our study identi-fied few specific components of infection control practice associated with hospital-associated infec-tions may reflect the lack of variation in many of the practices but also may be an indication that having the basic components of an infection control depart-ment is more important than the specific policies and procedures adopted.
The one variable we did find to be protective against infections was the availability of alcohol hand gel, which supports the importance of hand hygiene in preventing hospital-associated infections. Multiple lines of evidence, from the work of Ignaz Semmelweis in mid-19th century Vienna to nursery-based studies correlating better hand hygiene with decreased Staphylococcus aureus transmission to
in-fants9,10 and more recent studies demonstrating an association between the use of antiseptic soaps and decreased nosocomial infection rates,11–15 provide proof of the value of hand hygiene. The CDC and many other experts promote hand hygiene as the single most important measure in the prevention of hospital-associated infections.4Despite the evidence and expert opinion supporting hand hygiene, many studies have shown that health care workers perform it ⬍50% of the times they should.14,16–20Commonly cited barriers to health care worker hand hygiene include lack of time and the skin damage that accom-panies frequent washing with soap and water. Alco-hol-based hand gels address these barriers, because they require a fraction of the time for effective hand hygiene21 and they are less damaging to skin than soap and water.22,23 In addition, alcohol hand gels appear to be more effective in killing many microor-ganisms,21,24–29 and a few studies demonstrated in-creased frequency of hand hygiene and dein-creased frequency of hospital-associated infections with pro-vision of alcohol hand gel in the context of institu-tion-wide hand hygiene campaigns.15,30 Given the benefits of alcohol hand gel, the CDC now calls for its use as the primary mode of hand hygiene, except when hands are visibly soiled, in its guidelines on hand hygiene in health care settings.4However, be-cause of poor activity against bacterial spores, pro-tozoan oocysts, and certain nonenveloped (nonli-pophilic) viruses, such as hepatitis A, it is recognized that alcohol hand gel should not be used in outbreak situations involving these organisms.
We cannot state with certainty why alcohol hand gel use was associated inversely with gastrointestinal infections and not with respiratory infections in this study. The finding could be attributable to the fact that, although contact transmission is an important mode of spread for the pathogens of both gastroin-testinal and respiratory infections, the agents of gas-troenteritis appear to be even more dependent on contact transmission than the agents of respiratory
TABLE 3. Infection Control Policies and Practices and the Associated Odds of Hospital-Associated Respiratory and Gastrointestinal Infections
Respiratory Infections Gastrointestinal Infections
OR 95% CI PValue OR 95% CI PValue
Hospital information
No. of ICPs per 100 beds* 0.89 0.53–1.48 .65 0.96 0.44–2.12 .92
Full-time equivalent of physician support† 0.82 0.54–1.24 .35 1.52 0.87–2.66 .14 Viral testing and cohort assignment
Viral testing (respiratory and gastrointestinal) 1.09 0.81–1.47 .57 0.92 0.62–1.36 .67 Cohort assignment (respiratory and gastrointestinal) 0.92 0.72–1.16 .47 0.87 0.66–1.16 .35 Visitor screening policies
Screening of children only 1.02 0.76–1.37 .89 1.20 0.95–1.52 .13
Screening of all visitors 0.90 0.56–1.46 .67 0.93 0.62–1.39 .72
Hand hygiene policies
Hand hygiene monitoring 0.89 0.67–1.19 .43 0.90 0.63–1.28 .55
Administrative resources 0.88 0.69–1.12 .31 0.84 0.60–1.17 .31
Communication resources 0.92 0.73–1.17 .51 0.99 0.75–1.30 .95
Alcohol hand gel
Multiple locations 0.91 0.72–1.16 .46 0.86 0.64–1.16 .31
Present for entire study 0.90 0.70–1.14 .38 0.66 0.49–0.88 .005
Each predictor of interest was examined individually in a model adjusting for covariates. ORs were adjusted for covariates in Table 1 but not for the other survey variables. ICP indicates infection control practitioner.
infections. In addition, rotavirus is a common cause of hospital-associated gastroenteritis and is relatively resistant to common hand hygiene agents but ap-pears to be more susceptible to alcohol hand gel.24,25 Therefore, alcohol hand gel may offer a greater rel-ative benefit against the pathogens of gastroenteritis. This study has several limitations. First, our data regarding infection control practices were collected through a retrospective survey. Most queries were about the presence of policies and were not neces-sarily a measure of practice. In addition, certain re-sponses might have been biased according to the infection control practitioners’ knowledge base and their level of awareness with respect to hospital-associated infections within their institutions. How-ever, for either of these factors to have confounded our associations, they would have had to be associ-ated with hospital-associassoci-ated infection rates. A num-ber of the infection control policies and practices that we examined exhibited little variation among insti-tutions, making it difficult for us to detect whether an association with infection rates existed. It is also possible that some of the infections we included were actually community-acquired infections rather than hospital-associated infections, despite our ef-forts to reduce misclassification. We do not think, however, that this would have introduced systematic bias. Finally, although we attempted to control for multiple sources of potential confounding in our analyses, it is possible that some residual confound-ing remained, because this was an observational study and not a randomized, controlled trial. Whether this systematically biased our results would depend on whether variations were associated with particular institutions, something we have no reason to suspect a priori.
Despite these limitations, our study resulted in important findings with respect to hospital-associ-ated infections among patients undergoing elective surgery, as well as infection control practices in the pediatric setting. Hospitals should support the use of alcohol hand gel, with the aim of decreasing hospi-tal-associated infection rates.
ACKNOWLEDGMENTS
This work was supported by the Children’s Hospital and Re-gional Medical Center Outcomes Research Program.
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DOI: 10.1542/peds.2004-2014
2005;115;e387
Pediatrics
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Danielle M. Zerr, Michelle M. Garrison, Amanda L. Allpress, Joan Heath and Dimitri
Patients: Variability and Associations in a Multicenter Pediatric Setting
Infection Control Policies and Hospital-Associated Infections Among Surgical
Services
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