A clinicoepidemiologic study was undertaken to investigate an apparent increase in frequency of nosocomial invasive filamentous fungal disease (NIFFD) in adult patients with acute leukemia hospitalized during a period of hospital construction, and to determine if a relationship existed between the construction activity and the acquisition of NIFFD.

The first study goal, to determine the incidence of NIFFD before and during construction, was approached by calculation of incidence rates of NIFFD in patients with acute leukemia, comparing 1982 and 1983 (a baseline period free of construction) to 1986 (a year when construction activity was at its peak). The second study goal, to identify risk factors for the development of NIFFD, was accomplished by reviewing the autopsy records of all patients with underlying hematologic disorders accompanied by granulocytopenia who died in our hospital from 1982 through 1986. Patients with and without autopsy evidence of NIFFD were then compared by univariate and multivariate (logistic regression) analysis to identify potential risk factors for the acquisition of NIFFD.

The incidence of NIFFD in patients with acute leukemia hospitalized during the period of hospital construction was significantly increased when compared to a baseline period without construction (11 per 139 versus 4 per 333, p < .001). Review of all granulocytopenic patients autopsied over the five-year interval 1982 through 1986 revealed duration of granulocytopenia and hospitalization during construction to be risk factors for NIFFD by univariate analysis (p < .005). Logistic regression showed duration of granulocytopenia to be a highly significant independent risk factor (p < .01) and construction activity to be a probable independent risk factor (p = .09). The effect of construction on risk of NIFFD was most striking in those patients granulocytopenic for less than 40 days. The increased incidence of NIFFD occurred despite anticipation of this potential problem and compliance with published recommendations for infection control during periods of hospital construction.

Given the potentiating effect of construction activity on the occurrence of NIFFD in granulocytopenic patients and the suboptimal impact of standard recommended preventive measures, additional risk-reduction methods (i.e., surveillance culturing, prophylactic antifungal therapy, use of portable high efficiency particulate air filters) may be appropriate for patients expected to experience prolonged granulocytopenia (> 14 days) while hospitalized during periods of major construction activity involving excavation. Further studies will be necessary to define the roles of each of these modalities.

The cumulative risk of human immunodeficiency virus (HIV) infection over a healthcare career has rarely been estimated, but is more relevant to the description of an occupational hazard than the risk of seroconversion from a single exposure. We describe a model for assessing the individualized risk for HIV infection after multiple potential exposures over many years for surgeons and other operating room personnel, a high-risk group. For the average surgeon operating over a 30-year career on patients with an HIV seroprevalence of 0.01, the cumulative risk is estimated at 1%. The same surgeon operating on patients with a seroprevalence of 0.10 has an estimated cumulative risk of 10%. These risks may vary dramatically depending on the assumed rate of skin punctures during surgery. Healthcare workers need to be aware of the cumulative risk from multiple exposures to infectious blood and body fluids, to follow proposed suggestions for the reduction of percutaneous blood exposures and to assist in developing new technology to further reduce these risks. Failure to protect these professionals could result in the reduction of services for the approximately 1 to 1.5 million HIV-infected persons in the United States.

Glove-wearing attitudes of 375 physicians, representing 56% of all physicians surveyed, were ascertained. Although the majority were comfortable with their current glove use, 33% preferred wearing them more frequently. The most common reasons for not wearing gloves were a low likelihood of disease transmission and fear of offending patients. Many physicians felt that more frequent glove use in examining human immunodeficiency virus- (HIV)-positive patients might reduce rapport and diminish the adequacy of physical examination procedures, but only 11% felt that increased glove use would compromise overall care of HIVpositive patients. With regard to all patients, 33% felt that increased glove use in examinations would compromise care. Additionally, 56% of physicians stated that they were somewhat concerned about HIV infection. Glove-wearing preferences were significantly associated with greater concern about infection, a younger age and more frequent exposure to blood and body secretions. Contact with high-risk patient groups was not associated with glove-wearing preferences.

Infection control guidelines are now widely used in controlling nosocomial infection. For instance, the guidelines published by the Centers for Disease Control (CDC) are now successfully diffused and available in over 80% of the hospitals in the United States.

Before introducing any guideline, it should be carefully reviewed and evaluated. Because guidelines can only benefit patients after they are successfully implemented, the review should focus on the implementation process. A review scheme focusing on implementation was developed. In this scheme, an attempt was made to identify the guideline recommendations already being practiced in the hospital, recommendations requiring extra resources before they could be implemented and recommendations resisted by the hospital staff. We describe the review scheme and a study to assess its validity when used by infection control nurses (ICNs) in Hong Kong

The recent emphasis on outcome assessment has required hospitals not only to practice high quality care but also to prove that they do so. In search of leadership, many hospitals have turned to epidemiologists and infection control practitioners (ICPs), arguing that there are strong parallels between their activities and those of quality assurance. Both have the same ultimate goal of improving the health of the patient. The principles of surveillance, data management and problem solving used in epidemiology apply also to quality assurance. As advisers, participants or leaders, epidemiologists and ICPs are being drawn irresistibly into the field of quality assurance.

The need for leadership has arisen because the assessment of quality is a surprisingly complex task. Initial approaches are often unstructured and designed to fulfill the requirements of various regulatory agencies rather than to improve the delivery of care. In addition, quality assurance is costly, and financial restrictions on medicine are increasing. It is time to take a serious look at the cost-effectiveness of quality assurance and apply the techniques of medical decision analysis to combat the inefficiency and ineffectiveness that often dominate the field.

Many hospital epidemiologists (HE) and infection control practitioners (ICPs) find criticism a product of controlling infection because as change agents, these healthcare workers are often perceived as being highly critical. Criticism of epidemiologists and ICPs may appear in a number of ways. Staff may perceive the HE/ICP in a criticizing role because monitoring duties usually require investigative behavior that can be misinterpreted as spying. Staff may feel that epidemiologists do not understand the real work situation, because HEs and ICPs often do not actively care for patients and sometimes dictate that familiar routines be replaced by new procedures. This is especially true when the new procedures appear to take more time and effort than the familiar routine. In addition, the HE/ICP may be seen as picking on certain staff members when follow-up evaluation flags staff deficiencies that must be corrected.

Criticism is a subjective perception, but staff who perceive the change agent as critical may impede the change process. All too often, staff who feel criticized get angry and defensive, and become less willing to cooperate. Instead of quickly being able to modify unacceptable staff behavior, the HE/ICP may find that staff resistance and negativism will obstruct the implementation of even a minor change. Staff energy will be spent justifying the undesired behavior. Some staff even fantasize about eliminating the roles of the epidemiologist and ICPs, and may be heard to say, “We got our work done before they came. Besides, how does all this monitoring really help patient care? With this nursing shortage, the ICP could help us more by taking part in real patient care.” The ICP and HE do not generate known income for the hospital and many times they create additional work and advocate that extra monies be spent. Consequently, even an administrator might become critical of these change agents.