Dick E. Zoutman, MD, FRCPC, and B. Douglas Ford, MA Kingston, Ontario, Canada
Dick E. Zoutman, MD, FRCPC, and B. Douglas Ford, MA Kingston, Ontario, Canada
Background: The Resources for Infection Control in Hospitals (RICH) project assessed infection control programs and rates of an-
tibiotic-resistant organisms (AROs) in Canadian acute care hospitals in 1999. In the meantime, the severe acute respiratory syn-
drome (SARS) outbreak and the concern over pandemic influenza have stimulated considerable government and health care
institutional efforts to improve infection control systems in Canada.
Methods: In 2006, a version of the RICH survey similar to the original RICH instrument was mailed to infection control programs in
all Canadian acute care hospitals with 80 or more beds. We used x2, analysis of variance, and analysis of covariance analyses to test
for differences between the 1999 and 2005 samples for infection control program components and ARO rates.
Results: 72.3% of Canadian acute care hospitals completed the RICH survey for 1999 and 60.1% for 2005. Hospital size was con-
trolled for in analyses involving AROs and surveillance and control intensity levels. Methicillin-resistant Staphylococcus aureus
(MRSA) rates increased from 1999 to 2005 (F 5 9.4, P 5 .003). In 2005, the mean MRSA rate was 5.2 (standard deviation [SD],
6.1) per 1000 admissions, and, in 1999, it was 2.0 (SD, 2.9). Clostridium difficile-associated diarrhea rates trended up from 1999
to 2005 (F 5 2.9, P 5 .09). In 2005, the mean Clostridium difficile-associated diarrhea rate was 4.7 (SD, 4.3), and, in 1999, it
was 3.8 (SD, 4.3). The proportion of hospitals that reported having new nosocomial vancomycin-resistant Enterococcus (VRE) cases
was greater in 2005 than in 1999 (x2 5 10.5, P 5 .001). In 1999, 34.5% (40/116) of hospitals reported having new nosocomial VRE
cases, and, in 2005, 61.0% (64/105) reported new cases. Surveillance intensity index scores increased from a mean of 61.7 (SD,
18.5) in 1999 to 68.1 (SD, 15.4) in 2005 (F 5 4.1, P 5 .04). Control intensity index scores trended upward slightly from a mean
of 60.8 (SD, 14.6) in 1999 to 64.1 (SD, 12.2) in 2005 (F 5 3.2, P 5 .07). Infection control professionals (ICP) full-time equivalents
(FTEs) per 100 beds increased from a mean of 0.5 (SD, 0.2) in 1999 to 0.8 (SD, 0.3) in 2005 (F 5 90.8, P , .0001). However, the
proportion of ICPs in hospitals certified by the Certification Board of Infection Control decreased from 53% (SD, 46) in 1999 to
38% (SD, 36) in 2005 (F 5 8.7, P 5 .004).
Conclusion: Canadian infection control programs in 2005 continued to fall short of expert recommendations for human resources
and surveillance and control activities. Meanwhile, nosocomial MRSA rates more than doubled between 1999 and 2005, and hos-
pitals reporting new nosocomial VRE cases increased 77% over the same period. Although investments have been made toward
infection control programs in Canadian acute care hospitals, the rapid rise in ICP positions has not yet translated into marked im-
provements in surveillance and control activities. In the face of substantial increases in ARO rates in Canada, continued efforts to
train ICPs and support hospital infection control programs are necessary. (Am J Infect Control 2008;n:nnn-nnn.)
1
ARTICLE IN PRESS
2 Vol. n No. n Zoutman and Ford
need for effective infection control programs.3-5 We ex- regional representation. If differences in composition
amined the extent to which infection control program between the 1999 and 2005 samples were found for
resources and activities improved from 1999 to 2005 in hospital size, hospital teaching status, or regional rep-
Canadian acute care hospitals and whether ARO rates resentation, regression analyses were used to test their
have changed during the same time frame. association with dependent variables.
ANOVA or analysis of covariance (ANCOVA), depend-
METHODS ing on the regression analysis, were used to test for dif-
ferences between the 1999 and 2005 samples for MRSA
Survey
and CDAD rates, surveillance and control index scores,
In March of 2006, all acute care hospitals in Canada physician and doctoral level professionals and secre-
with 80 or more beds were mailed a bilingual cover tarial service hours, infection control professional
letter and the 2005 version of the RICH survey regard- (ICP) hours, ICP experience in infection control, and
ing the state of infection control in their facility. A list ICP infection control certification levels. Multiple t tests
of 233 eligible hospitals was compiled from the 2005 with the Bonferroni correction were used to examine
Canadian Health Facilities Directory. The staff mem- for regional differences between 1999 and 2005 for
ber most responsible for the infection control pro- MRSA and CDAD rates, surveillance and control index
gram was asked to complete the survey. If an scores, and ICP staffing levels.6 The conservative Bon-
infection control program was responsible for multi- ferroni correction decreases the incidence of false-pos-
ple hospitals within a larger health organization, ag- itive results when conducting multiple comparisons by
gregated data were accepted if data for individual decreasing a levels as the number of comparisons
hospitals were not available. Advertisements in the rises.
Canadian Journal of Infection Control and on the Com- The VRE dependent variable was dichotomized as
munity and Hospital Infection Control Association hospitals with and without new nosocomial VRE cases
(CHICA)-Canada Web site (www.chica.org) and memos because, in 1999, two thirds of hospitals in the RICH
to CHICA-Canada chapter presidents were used to op- sample did not have any new nosocomial VRE cases.
timize response, and nonresponders were sent a sec- Logistic regression analysis was used to test for differ-
ond survey. ences between the 1999 and 2005 samples for the
The 2005 version of the RICH survey incorporated presence of VRE, hospitals with secretarial support,
the original RICH instrument,1 allowing for the calcula- hospitals with physician and doctoral level profes-
tion of surveillance and control index scores and the sionals providing service, hospitals with physician
assessment of infection control program resources (Ta- and doctoral professionals with formal infection con-
ble 1). The survey items that assessed program re- trol training, and computer resources. The x2 test anal-
sources and composed the surveillance and control ysis with Bonferroni correction was used to test for
indices were identical in the 1999 and 2005 versions regional differences between 1999 and 2005 for the
of the survey. The 23 items in the surveillance index as- presence of new nosocomial VRE cases.
sessed the collection and dissemination of infection
data, and the 44 items in the control index measured RESULTS
the activities and policies directed toward the reduction
The response rate for the 2005 survey was 60.1%;
of infections in hospitals. Scores of 100 on the surveil-
lance and control indices indicated that all effective ac- 113 surveys were received, representing 140 of 233 el-
igible facilities. Eighteen surveys were received from
tivities were being conducted. Respondents were asked
larger organizations that represented up to 4 eligible
to provide the number of any and all (colonized and in-
hospitals. One survey was returned without identifying
fected) new nosocomial cases of MRSA, VRE, and CDAD
the respondent or the hospital, and 2 were not included
for 2005 in their hospital. The identical method was
because of incomplete information. The response rate
used to assess MRSA, VRE, and CDAD rates in Canadian
for the 1999 survey was 72.3%.1
acute care hospitals in 1999.2
Sample characteristics
Statistical analysis
The size of the respondent hospitals increased in the
Data were analyzed with use of StatView version 5.0 6 years between surveys (F 5 4.5, P 5 .03). Mean hos-
(SAS Institute, Cary, NC). Analysis of variance (ANOVA) pital size in 1999 was 292.4 (standard deviation [SD],
analysis was used to test for differences between the 237.6) beds with a median of 230.0. Mean hospital
1999 and 2005 samples for hospital size, and x2 analy- size in 2005 was 363.1 (SD, 292.9) beds with a median
sis was used to test for differences between the 1999 of 289.0. An examination of the proportion of hospitals
and 2005 samples for hospital teaching status and in the 1999 and 2005 samples for 3 size
ARTICLE IN PRESS
Zoutman and Ford n 2008 3
Table 1. Items included in the Resources for Infection categories—hospitals with less than 200 beds, hospi-
Control in Hospitals survey questionnaire tals with 200 to 399 beds, and hospitals with 400
plus beds—indicated a trend for hospital size category
Hospital characteristics
Bed numbers differences between the samples (x2 5 5.7, P 5 .06).
Admissions The post hoc cell contributions showed that hospitals
New nosocomial cases of antibiotic-resistant organisms with less than 200 beds comprised a greater proportion
MRSA of the 1999 sample than the 2005 sample (Z 5 2.3, P 5
VRE
.01).
CDAD
Infection control program resources The proportion of teaching hospitals participating in
ICPs the survey did not differ between 1999 and 2005 (x2 5
Time devoted to infection control and specific activities 0.5, P 5 .5). In 1999, 23.4% (34/145) of the sample was
Professional category composed of teaching hospitals, and, in 2005, 27.3%
Certified by Certification Board of Infection Control
(30/110) of the sample was teaching hospitals.
Physicians/doctoral professionals
Time devoted to infection control and specific activities Hospitals were grouped into 4 geographic regions:
Infection control training the West region consisted of hospitals in British Co-
Secretarial support provided to infection control program lumbia, Alberta, Saskatchewan, and Manitoba; the
Laboratory provinces of Ontario and Quebec were each separate
Access to daily reports on cultures
regions; and the Atlantic region consisted of New
Surveillance cultures for evaluating possible outbreaks
Computers Brunswick, Nova Scotia, Prince Edward Island, New-
Computers used for tabulation of infection data and infection foundland, and Labrador. Regional representation
reports did not differ between the 1999 and 2005 samples
Use of statistical software to analyze data collected (x2 5 2.6, P 5 .5).
References
Infection control journals and texts
Internet access Association of hospital size with dependent
Current Health Canada guidelines on preventing nosocomial variables
infections
Surveillance/case finding of infections Larger hospitals were associated with higher MRSA
Denominator data collected
rates (r 5 0.19, P 5 .005), with higher CDAD rates (r 5
Specific statistics collected for infections on wards, units, or service
Infections involving particular anatomic sites or medical devices 0.22, P 5 .003), and with more new nosocomial VRE
Specific statistics collected for MRSA, VRE, CDAD cases (x2 5 31.5, P , .0001). Higher surveillance in-
Surgical site infections calculated and reported to surgeons dex scores (r 5 0.23, P 5 .0002) and higher control
Case-finding methods used to detect new cases of nosocomial index scores (r 5 0.34, P , .0001) were associated
infections
with the number of hospital beds. Hospital size was
Infection control activities
Infection control teaching activities not associated with ICP full-time equivalents (FTEs)
Communicated hospital’s infection data to patient care staff per 100 beds (r 5 20.01, P 5 .9) nor with the propor-
Circulated scientific information on infection control to patient care tion of ICPs Certification Board of Infection Control
staff (CBIC) certified (r 5 0.04, P 5 .5) nor with years of in-
Infection control authority
fection control experience of ICPs (r 5 0.08, P 5 .2).
Direct authority to close wards or units to further admissions
Direct authority to have patients placed in isolation The percentage of infection control programs with
Infection control policies physician and or doctoral level professionals provid-
Isolation precautions for patients with VRE ing service was positively associated with hospital
Isolation precautions for patients with MRSA size (x2 5 18.6, P , .0001) as was whether physician
Insertion, maintenance, and changing of IVs, tubing, and solutions
and or doctoral level professionals had infection
Respiratory precautions for tuberculosis and other airborne
infections control training or expertise (x2 5 3.7, P 5 .05).
Aseptic insertion and maintenance of closed drainage of Foley Physician and doctoral level professionals hours per
catheters 250 beds were not associated with hospital size (r 5
Routine system for changing breathing circuits on patients 20.11, P 5 0.2). Hospital size was associated with
undergoing ventilation
having secretarial support (x2 5 20.6, P , .0001);
Isolation precautions for patients with diarrhea associated with
Clostridium difficile however, not with the number of secretarial hours (r
The indications, drug choices, timing, and duration of 5 20.03, P 5 .7). Whether infection control programs
perioperative antibiotics used computers to generate infection reports was
MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Entero- correlated with hospital size (x2 5 16.2, P , .0001),
cocci; CDAD, Clostridium difficile-associated diarrhea. and hospital size was not associated with whether sta-
tistical or specialized infection control software was
used (x2 5 2.1, P 5 .1).
ARTICLE IN PRESS
4 Vol. n No. n Zoutman and Ford
Table 2. Unpaired means comparisons for MRSA and CDAD rates in 1999 and 2005 by Canadian region
Mean MRSA rate/1000 Mean CDAD rate/1000
admissions (SD) admissions (SD)
Region 1999 2005 P value* Region 1999 2005 P value
West (n 5 59) 1.6 (2.9) 3.6 (3.5) .02 West (n 5 49) 3.3 (3.3) 4.5 (4.7) .3
Ontario (n 5 85) 2.8 (2.9) 3.8 (3.4) .1 Ontario (n 5 71) 4.2 (4.0) 3.6 (2.1) .4
Quebec (n 5 37) 2.8 (3.8) 11.2 (9.6) .0009 Quebec (n 5 27) 7.9 (7.5) 8.6 (6.2) .8
Atlantic (n 5 37) 0.2 (0.3) 5.1 (6.6) .002 Atlantic (n 5 31) 1.7 (1.2) 3.3 (3.4) .08
Overall (n 5 222) 2.0 (2.9) 5.2 (6.1) .003 Overall (n 5 182) 3.8 (4.3) 4.7 (4.3) .09
MRSA, methicillin-resistant Staphylococcus aureus; CDAD, Clostridium difficile-associated diarrhea.
*Because of the Bonferroni correction, regional comparisons in this Table are not significant unless the corresponding P value is less than .0125.
3.8 (SD, 4.3). Regional CDAD rates did not differ from
1999 to 2005 (Table 2). Quebec, control index scores increased significantly
The proportion of hospitals that reported having from 53.3 (SD, 15.7) in 1999 to 64.5 (SD, 10.0) in
new nosocomial VRE cases, controlling for the number 2005 (t 5 2.7, P 5 .01) (Table 4).
of hospital beds, was greater in 2005 than in 1999 (x2 5
10.5, P 5 .001). In 1999, 34.5% (40/116) of hospitals re- Human resources
ported having new nosocomial VRE cases, and, in ICP FTEs per 100 beds increased from a mean of 0.5
2005, 61.0% (64/105) of hospitals reported having (SD, 0.2) in 1999 to 0.8 (SD, 0.3) in 2005 (F 5 90.8, P ,
new nosocomial VRE cases. The proportion of hospi- .0001). ICP FTEs per 100 beds increased in Ontario (t 5
tals in Quebec with new nosocomial VRE cases in- 6.9, P , .0001), Quebec (t 5 7.8, P , .0001), and the At-
creased from 1999 to 2005 from 21.1% (4/19) lantic region (t 5 3.1, P 5 .004) from 1999 to 2005 (Ta-
hospitals to 72.2% (13/18) (x2 5 9.7, P 5 .002) (Table ble 5). The proportion of ICPs in hospitals certified by
3). In 2005, the mean VRE rate across Canada was 1.0 the CBIC decreased from 53% (SD, 46) in 1999 to
(SD, 1.8) per 1000 admissions, and, in 1999, the overall 38% (SD, 36) in 2005 (F 5 8.7, P 5 .004). The mean
rate was 0.4 (SD, 1.5). years of infection control experience of ICPs decreased
Surveillance and control indices from 9.0 (SD, 5.8) in 1999 to 7.2 (SD, 5.2) in 2005 (F 5
6.2, P 5 .01).
Overall, surveillance index scores, controlling for the The percentage of infection control programs with
number of hospital beds, increased only slightly from a physician and or doctoral level professionals providing
mean of 61.7 (SD, 18.5) in 1999 out of a maximum of service, controlling for hospital size, was similar in
100 to 68.1 (SD, 15.4) in 2005 (F 5 4.1, P 5 .04). In On- 1999 (71.7%) and 2005 (70.9%) (x2 5 1.0, P 5 .3). In
tario, however, surveillance index scores increased in a hospitals with physician and doctoral level profes-
significant fashion from 63.5 (SD, 15.9) in 1999 to 72.4 sionals providing service to infection control programs,
(SD, 12.7) in 2005 (t 5 2.9, P 5 .004) (Table 4). physician and doctoral level professionals mean hours
Control index scores, controlling for the number of of service per week per 250 beds in 1999 was 6.8 (SD,
hospital beds, trended upwards slightly from a mean 8.0) and similar to the 8.5 hours of service provided in
of 60.8 (SD, 14.6) out of a maximum of 100 in 1999 2005 (SD, 11.2) (F 5 1.4, P 5 .2). The percentage of
to 64.1 (SD, 12.2) in 2005 (F 5 3.2, P 5 0.07). In infection control programs with physician and or
ARTICLE IN PRESS
Zoutman and Ford n 2008 5
Table 4. Unpaired means comparisons for surveillance and control index scores in 1999 and 2005 by Canadian region
Mean surveillance Mean control
scores (SD) scores (SD)
Region 1999 2005 P value* 1999 2005 P value
West (n 5 69) 64.2 (18.1) 64.4 (16.6) .96 63.0 (16.9) 60.3 (11.7) .5
Ontario (n 5 91) 63.5 (15.9) 72.4 (12.7) .004 61.8 (12.6) 67.5 (13.3) .04
Quebec (n 5 42) 46.3 (22.5) 61.0 (17.9) .03 53.3 (15.7) 64.5 (10.0) .010
Atlantic (n 5 37) 70.2 (9.7) 70.2 (14.4) .98 62.7 (9.9) 60.0 (10.1) .4
Overall (n 5 244) 61.7 (18.5) 68.1 (15.4) .04 60.8 (14.6) 64.1 (12.2) .07
*Because of the Bonferroni correction, regional comparisons in this Table are not significant unless the corresponding P value is less than .0125.
Table 5. Unpaired means comparisons for ICP staffing software, and, in 2005, 35% (36/102) used statistical
levels in 1999 and 2005 by Canadian region or specialized infection control software.
Mean ICP FTEs per 100
beds (SD)
DISCUSSION
Region 1999 2005 P value* There have been 2 major events in Canada since
1999 that put hospital infection prevention and control
West (n 5 70) 0.43 (0.17) 0.55 (0.24) .02
under the spotlight in a very public way: The SARS out-
Ontario (n 5 95) 0.49 (0.21) 0.87 (0.33) ,.0001
Quebec (n 5 42) 0.33 (0.12) 0.73 (0.21) ,.0001 break in 2003 in Toronto, Ontario, and the CDAD out-
Atlantic (n 5 39) 0.54 (0.27) 0.84 (0.35) .004 break in several cities in Quebec between 2002 and
Overall (n 5 251) 0.45 (0.21) 0.77 (0.32) ,.0001 2004. Both of these outbreaks that affected Canadian
ICP, infection control professionals; FTEs, full-time equivalents. hospitals have been the subject of public commissions
*Because of the Bonferroni correction, regional comparisons in this Table are not sig- or inquiries as well as intense media scrutiny.7-12 The
nificant unless the corresponding P value is less than .0125.
SARS Commission in Ontario and the National Advi-
sory Committee on SARS and Public Health among
others placed high emphasis on resources being placed
doctoral level professionals who had infection control into infection prevention and control programs in Ca-
training, controlling for hospital size, was similar in nadian hospitals. It was against this backdrop that we
1999 (81.7%) and 2005 (88.5%) (x2 5 0.7, P 5 .4). conducted the present study to evaluate the state of in-
The percentage of infection control programs with fection control programs and ARO rates in Canadian
secretarial support, controlling for hospital size, was acute care hospitals and compare them with those of
similar in 1999 (69.0%) and 2005 (67.3%) (x2 5 1.4, our previous study of 1999.1,2 The similar methodol-
P 5 .2). Among those hospital infection control pro- ogy used in both studies allowed for direct compari-
grams with secretarial support, secretarial hours per sons between infection control programs and ARO
250 beds was greater in 2005 than in 1999 (F 5 4.6, rates in 1999 and 2005. Furthermore, the response
P 5 .03) with a mean of 12.5 (SD, 9.2) hours per 250 rates of the 1999 and 2005 surveys indicated that
beds and 9.1 (SD, 10.7) for 2005 and 1999, respectively. both samples were representative of Canadian acute
Computer resources care hospitals with 80 or more acute care beds.
ARO rates are increasing in Canada and many juris-
A significantly greater percentage of infection con- dictions around the world.13-17 The overall nosocomial
trol programs in 2005 used computers for the purposes MRSA rates for Canadian acute care hospitals partici-
of tabulating infection data and preparing reports of in- pating in our survey more than doubled between
fections, controlling for hospital size, than in 1999 (x2 1999 and 2005, and the number of hospitals reporting
5 17.3, P , .0001). In 1999, 67% (97/145) of infection new nosocomial VRE cases in Canada increased 77%
control programs used computers for tabulating and over the same period. The MRSA and VRE rates of the
reporting infection data, and, by 2005, 93% (102/110) present study are in line with the nosocomial MRSA
used computers. Among those infection control pro- and VRE rates reported for large Canadian teaching
grams that used computers for the purposes of tabulat- hospitals.16,17 We did not find national or regional in-
ing infection data and preparing reports of infections, creases in nosocomial CDAD between 1999 and 2005.
the use of statistical or specialized infection control This may have been due to infection control efforts di-
software decreased from 1999 to 2005 (x2 5 8.2, P 5 rected toward CDAD that resulted from the numerous
.004). In 1999, 56% (54/97) of infection control pro- deaths associated with outbreaks of the hypervirulent
grams used statistical or specialized infection control NAP1 strain in Quebec between 2002 and 2004.10
ARTICLE IN PRESS
6 Vol. n No. n Zoutman and Ford
Nevertheless, CDAD rates were higher in Quebec than surveillance and control activities and infection control
the rest of Canada in 1999 (t 5 3.4, P 5 .001) and program human resources.18-20 Taking into account
2005 (t 5 4.7, P , .0001). hypervirulent C difficile strains, the predicted influenza
Surveillance scores increased roughly 6%, and con- pandemic, and increasing rates of MRSA and VRE,
trol scores trended up from 1999 to 2005. Despite the there continues to be great need for ongoing invest-
minor increases in surveillance and control intensity, ment in infection control programs.3-5,21 If Canada is
15% of hospitals in our 2005 sample scored less than to achieve widespread control of infections in acute
50 on the surveillance index, indicating that they con- care hospitals, increased investments in infection con-
ducted less than half of the recommended surveillance trol human resources are required in the form of more
activities. Only 27% of infection control programs con- infection control professionals, their training, and cer-
ducted greater than 80% of recommended surveillance tification with CBIC. Infection control programs also
activities. The findings are similar for control activities; require physicians trained in infection control, surveil-
10% of infection control programs scored less than 50 lance tools, and support staff to mount effective control
on the control index, and only 11% scored greater than programs and to report on nosocomial infection rates.
80%. The size and scope of the ARO problem is increasing,
The situation is mixed as to whether human re- yet there is accumulating evidence that properly de-
sources available to infection control programs im- signed and executed infection control programs are
proved from 1999 to 2005. Physician, doctoral highly effective and cost beneficial.21 To not continue
professionals, and secretarial support to infection con- to make these investments now is very shortsighted
trol programs changed little from 1999 to 2005, and suggests that we may have already forgotten the
whereas ICP FTEs per 100 beds increased 60% overall. lessons we were to have learned from the outbreaks
However, even with increased ICP staffing, less than of SARS and hypervirulent C difficile.
one quarter (22.6%) of hospitals had the recommended
1 FTE ICP per 100 beds in 2005.18 The proportion of The authors thank the survey respondents, CHICA-Canada and its chapters for their
efforts, and the Public Health Agency of Canada for financial support.
ICPs with CBIC certification actually decreased from
1999 to 2005. This decrease in certification levels
may be due to the requirement for recently hired References
ICPs to practice in infection control for 2 years with a 1. Zoutman DE, Ford BD, Bryce E, Gourdeau M, Herbert G, Henderson E,
minimum of 800 hours experience before being eligi- et al. The state of infection surveillance and control in Canadian acute
ble to write the CBIC certification examination care hospitals. Am J Infect Control 2003;31:266-72.
(www.cbic.org). On average, ICPs had almost 2 years 2. Zoutman DE, Ford BD, Canadian Hospital Epidemiology Committee,
less experience in infection control in 2005 when com- Canadian Nosocomial Infection Surveillance Program, Health Canada.
The relationship between hospital infection surveillance and control
pared with ICPs in 1999, reflecting recent entrants into activities and antibiotic resistant pathogen rates. Am J Infect Control
the field. 2005;33:1-5.
A greater percentage of ICPs used computers for tab- 3. Macias AE, Ponce-de-Leon S. Infection control: old problems and new
ulating infection data and preparing reports of infec- challenges. Arch Med Res 2005;36:637-45.
tions in 2005 than in 1999; however, the overall use 4. Shaw K. The 2003 SARS outbreak and its impact on infection control
practices. Public Health 2006;120:8-14.
of statistical or specialized infection control software 5. Goldrick BA, Goetz AM. Pandemic influenza: what infection control
decreased from 1999 to 2005. The decrease in the professionals should know. Am J Infect Control 2007;35:7-13.
use of statistical or specialized infection control soft- 6. Blair RC, Taylor RA. Biostatistics for the health sciences. Upper Saddle
ware might be because fewer of the recently hired River, NJ: Pearson Prentice Hall; 2008.
ICPs have received training to use these programs 7. Commission to Investigate the Introduction and Spread of Severe
Acute Respiratory Syndrome (SARS). The SARS Commission. 2006.
and/or there is a lack of resources for the software Available at: http://www.sarscommission.ca/index.html. Accessed Feb-
and more use of spreadsheet and database programs ruary 14, 2008.
that are available on many hospital computer systems. 8. Ontario Expert Panel on SARS and Infectious Disease Control. Final
Crises appear to drive increases in infection surveil- Report of the Ontario Expert Panel on SARS and Infectious Disease
lance and control resources and activities. Increases in Control. 2004. Available at: http://www.health.gov.on.ca/english/
public/pub/ministry_reports/walker04/walker04_mn.html. Accessed
ICP staffing and the intensity of control activities in February 14, 2008.
Quebec coincided with the CDAD outbreak in Quebec. 9. The Standing Senate Committee on Social Affairs, Science and
Similarly, increases in ICP staffing and the intensity of Technology. Reforming health protection and promotion in Canada:
surveillance activities in Ontario coincided with the time to act. 2003. Available at: http://www.parl.gc.ca/37/2/parlbus/
SARS outbreak of 2003. Despite these crises-motivated commbus/senate/Com-e/SOCI-E/rep-e/repfinnov03-e.htm#_ftnref3.
Accessed February 14, 2008.
influxes of resources, Canadian infection control 10. Pepin J, Valiquette L, Cossette B. Mortality attributable to nosocomial
programs in 2005 continue to fall short of expert rec- Clostridium difficile-associated disease during an epidemic caused by a
ommendations with respect to the intensity of hypervirulent strain in Quebec. CMAJ 2005;173:1037-42.
ARTICLE IN PRESS
Zoutman and Ford n 2008 7
11. Eggertson L. Quebec strikes committee on Clostridium difficile. CMAJ 17. Ofner-Agostini M, Johnston BL, Simor AE, Embil J, Matlow A, Mulvey
2004;171:123. M, et al, Canadian Nosocomial Infection Surveillance Program. Vanco-
12. Pindera L. C difficile inquest too narrow as ‘‘Quebec strain’’ goes inter- mycin-resistant Enterococci in Canada: results from the Canadian
national. CMAJ 2007;167:915-6. Nosocomial Infection Surveillance Program, 1999-2005. Infect Con-
13. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence trol Hosp Epidemiol 2008;29:271-4.
and resurgence of methicillin-resistant Staphylococcus aureus as a pub- 18. O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection
lic-health threat. Lancet 2006;368:874-85. control programs in US health care facilities: Delphi project. Am J
14. Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S, et al. Infect Control 2002;30:321-33.
Invasive methicillin-resistant Staphylococcus aureus infections in the 19. Health Canada, Division of Occupational and Nosocomial Infections.
United States. JAMA 2007;298:1763-71. Development of a resource model for infection prevention and con-
15. Kuijper EJ, Coignard B, Tüll P, ESCMID Study Group for Clostridium dif- trol programs in acute, long-term, and home care settings: conference
ficile, EU Member States, European Centre for Disease Prevention proceedings of the Infection Prevention and Control Alliance. Am J
and Control. Emergence of Clostridium difficile-associated disease in Infect Control 2004;32:2-6.
North America and Europe. Clin Microbiol Infect 2006;12(Suppl 6): 20. Scheckler WE, Brimhall D, Buck AS, Farr BM, Friedman C, Garibaldi
2-18. RA, et al. Requirements for infrastructure and essential activities of
16. Simor AE, Ofner-Agostini M, Gravel D, Varia M, Paton S, McGeer A, et al, infection control and epidemiology in hospitals: a consensus panel
Canadian Nosocomial Infection Surveillance Program (CNISP). Surveil- report. Am J Infect Control 1998;26:47-60.
lance for Methicillin-Resistant Staphylococcus aureus in Canadian hospi- 21. Farr B. What to think if the results of the National Institutes of Health
tals—a report update from the Canadian Nosocomial Infection randomized trial of methicillin-resistant Staphylococcus aureus and van-
Surveillance Program. Can Commun Dis Rep 2005;31:1-7 comycin-resistant Enterococcus control measures are negative (and
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/05vol31/dr3103ea.html. other advice to young epidemiologists): a review and an au revoir.
Available at: Accessed February 14, 2008. Infect Control Hosp Epidemiol 2006;27:1096-106.