The first two articles in this series outlined the widespread use of hospital surveillance for infection control programs and the potential use of surveillance for monitoring noninfectious nosocomial events. The third article focused on quality indicators as potential targets for hospital surveillance. Surveillance has been defined as the collection, collation, analysis, and dissemination of data. Several methods have been developed to perform this task in hospitals; the traditional method includes collection of data through extensive chart review, a very time- and labor-intensive process. Computerized methods have been developed for hospital surveillance: several personal computer-based programs in infection control are available, including NOSO 3 (Epi Systematics, Inc., Ft. Myers, Florida) and AICE (ICPA, Inc., Austin, Texas). In addition, the Centers for Disease Control (CDC) offer an IDEAS software program to facilitate collection of hospital data for inclusion in the National Nosocomial Infection Surveillance System. These systems offer added efficiencies in the analysis of data, but not in the collection of data. As surveillance in hospitals is expanded from infection control to other areas, more efficient means of data collection will be essential. The development and implementation of comprehensive hospital information systems offer the potential for improving, enlarging, and conducting more efficient hospital-wide surveillance. This article will review the hospital surveillance programs conducted with a hospital information system currently in use at LDS Hospital in Salt Lake City, Utah.

Long-term care facilities are comprised of a heterogeneous group of institutions caring for residential patients over prolonged periods of time. Included as long-term care facilities in this review are private and Veterans' Affairs (VA) nursing homes, rehabilitation centers, institutions for the developmentally disabled, and hospital wards for both long-term and intermediate care. Patients in long-term care facilities incur bacterial infections at a prevalence of 10% to 16%. These infections usually are caused by common bacterial pathogens that invade the compromised host residing within a complex physical environment. The high prevalence of institutional infections leads, in turn, to the need for multiple courses of antimicrobials or for hospitalization. This process selects strains more resistant to antibiotics, which are then available for repeated dispersal in the long-term care facility.

Infection control practices in long-term care facilities have been the subject of an increasing number of reports in the past few years. A recent review by Smith in this series outlined important problems regarding infection surveillance in long-term care facilities including: the lack of standard definitions of infection and the difficulty of applying Centers for Disease Control (CDC) definitions in long-term care facilities: the lack of a consensus on the best approach to infection surveillance in long-term care facilities; the lack of full-time commitment to infection control among long-term care facilities; and the lack of risk stratification of patients. For reasons mentioned previously, the effective solution to these problems will require the input of hospital-based infection control professionals. It would be ideal if, prior to this effort, these professionals could gain some experience regarding the important differences between the long-term care facility and the acute hospital setting.

In this article, the observations of a hospital epidemiologist who has consulted for several years with long-term care facilities will be discussed. Specifically, I will deal with experiences and problems I have dealt with in long-term care facilities that were either new to me or variations of hospital-based experience.

Healthcare providers need to be aware of the facts regarding the environmental impact of regulated medical wastes and be prepared to voice concern over unnecessary and costly regulations. The wash-ups of waste, a small percentage of which was medical waste, on the beaches on New York and New Jersey in the summers of 1987 and 1988 prompted an immediate response by state and federal governments. Although it was demonstrated that this medical waste did not originate in healthcare facilities,' the public demanded that their elected representatives do something about what they perceived to be the degradation of the environment and a risk to public health caused by “uncontrolled dumping” of “medical wastes” into the ocean. As a result of these and other occurrences, several environmental concerns regarding the treatment and disposal of medical waste were voiced by the public and acknowledged by the legislators. These included the following: aesthetic damage to the environment; potential public health problems associated with infectious agents in medical waste; and potential environmental contamination with hazardous chemicals and radioactivity associated with medical wastes.

Previous papers in this series have discussed design and analysis issues for epidemiologic data that can be presented in a 2 × 2 table.‘” the primary focus was on methods for determining the extent of association between a dichotomous disease state and a dichotomous risk factor. methods appropriate for cross-sectional, prospective, and retrospective studies using matched or unmatched samples were described.

In order to study the association between disease status and a dichotomous risk factor, it is often necessary to take into account other variables that may influence either the disease status or the risk factor. For example, Hemming, Overall, and Britt studied the association between the occurrence of nosocomial infections (risk factor) and mortality (disease status) in a large cohort of infants in a newborn intensive care unit. these authors analyzed the data using methods for summarizing the results from a single 2 × 2 table. However, because very low birth weight is associated strongly with both the acquisition of nosocomial infection and mortality, it may be more appropriate to control or adjust for the effects of birthweight.