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Hospital Infections

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Assignment 1: Issues in Public Health- Nosocomial Infections

Nosocomial infections are defined simply as hospital-acquired infections. These infections are not present initially and typically occur within 48 hours of a patient’s admission, within 3 days of discharge or approximately 30 days after an operation. (Inweregbu, Dave & Pittard, 2005) Not just in the United States, but also globally, such infections are rising significantly with no solutions available currently. And, though it is exceedingly difficult to gather reliable information, especially within smaller countries, it has been shown that hundreds of millions of individuals are impacted by such infections each year. Nosocomial infections are an endemic globally with high incidence in both developed and undeveloped countries. Such infections are particularly pertinent in both ICU and NICU patients. In America, it is typical to find that 4.5% of patients will fall ill to such infections when taking the entire population into consideration. European countries see a prevalence rate of approximately 7.1% when considering the population as a whole. These rates will become higher when looking at a sample such as the ICU or NICU where rate of infection can range from 30%-51%, taking into consideration, the longer the stay the greater the risk. (World Health Organization) However, when considering the low and middle-income populations of underdeveloped countries, these rates are considerably higher. It is estimated that up to 19.1% of patients will become sick with a secondary hospital acquired infection. These rates can range from three to nineteen times higher than a developed country depending on the type of infection. When considering the ICU and NICU, where all nosocomial infections are most prevalent, an underdeveloped country will typically have 42.7/1000 patients with an infection at the low end and up to 88.9% on the high end. The World Health Organization also estimates that in Sub Saharan Africa, nosocomial infections are responsible for 75% of deaths (World Health Organization). With such staggering numbers, that most of the world is unaware of, it is key to establish the indicators of such infections. In recent years, hospitals around the world have seen a rise in prolonged hospitals stays, readmissions and increasing financial losses all of which prompted research into such areas. Such trends have a direct relation to nosocomial infections and there are two likely indicators into these trends and infections. The first indicator of hospital-acquired infections would be quality of care. There has been a decrease in both sanitation and standard isolation procedures in hospitals globally, as well as issues with staff accountability and behavior. (Braun, Carr & Cheng, 2004) Such quality measures are much greater, as well as unavoidable in developing countries. These hospitals have limited resources, and are understaffed and overcrowded, thus indicating a more likely chance of secondary infections. (World Health Organization) The other major indicator is that of patient safety. When a patient with underlying medical conditions or a patient who has just undergone an invasive procedure is exposed to decreased quality, their safety is compromised tremendously. If such patients are exposed to unsanitary procedures or are not properly taken care of they’re almost twice as likely to get a nosocomial infection during their initial stay or soon there after, requiring readmission. Safety is also less likely to be practiced in developing countries, as there are no local or national guidelines or policies in regards to infection control measures. (Peterson & Walker, 2006)
The most obvious effects of decreased quality and decreased patient safety are the nosocomial infections themselves. Which infections are most prevalent in hospitals today? Globally, the infections patients acquire do not vary. In adult patients and most frequently the ICU, the infections likely to be found are urinary tract infections secondary to urinary catheters, blood stream infections due to central line placement, ventriculitis and meningitis secondary to internal medical devices, ventilator associated pneumonia, and MRSA. (Inweregbu, Dave & Pittard, 2005) When taking the neonatal intensive care unit as an example, you are likely to find patients acquiring pneumonia and staphylococcus. However, in underdeveloped countries, poor intrapartum and postnatal control practices almost triple the chances of a child getting such illnesses. (Huskins, Thaver, Bhutta, Abbas & Goldmann, 2008) One of the biggest outcomes of hospital-acquired infections is death. With rising prevalence rates, underlying illness, inadequate sanitary precautions and limited resources in some areas, the mortality rate can become significant. One of the only ways to decrease these infections and high mortality rates requires time, research and most importantly money. The most significant problem hospital administrators and epidemiologists are finding is the financial burden hospital acquired infections are causing hospitals and the financial burden it would take to fix it along with accountability and behavior change. Each year, hospitals are estimating they are losing $6.5 to $7 billion with a number equating to around $18 million in underdeveloped countries. (Roberts, Scott, Cordells, Solomon, steel, Kampe & Weinstein, 2003) Coupled with that are approximately 16 million extra days spent in the hospital and such costs are giving hospitals worldwide adding to the already extreme financial losses. (World Health Organization) With a solution nowhere in site, the downstream effects of nosocomial infections are grim. Without changes to quality of care, and more insight into patient safety, infections will continue to rise. This will continue to result in unnecessary and untimely death, as well as prolonged hospital stays, the possibility of long-term disability and financial losses that will only continue to rise even more.

Assignment 2: Core Functions and Essential Services

Nosocomial or hospital-acquired infections are a leading, preventable, global endemic. Through the core functions and essential services of public health, we can evaluate the framework of assessment, policy development and assurance as a whole, as well as obtain a deeper understanding of how they relate to hospital-acquired infections.
Assessment:
The first part of the core functions and essential services chart are within the area of assessment. Within assessment, you will find the monitoring of health, as well as diagnose and investigate, which is interrelated, and one of the areas where hospitals have the most ability to prevent nosocomial infections. Currently, hospitals all over the world know they must increase their efforts to prevent nosocomial infections, and the best way to begin this effort is to identify their high-risk population and patients. Such identification is of the utmost importance for hospitals as this will enable them to recognize how likely patients at their hospital are to develop a nosocomial infection. For example, if a hospital has knowledge that many of their elderly patients have COPD, and there is a chance they may end up on a ventilator in the future, hospitals could achieve better monitoring practices of such patients in an attempt to prevent secondary pneumonia. Typically, the elderly, as well as patients in the NICU and ICU will be at the highest risk of developing a hospital-acquired infection. In terms of monitoring the health status of such patients once they are in the hospital, routine checks of vital signs, including blood pressure and fever are good measures to take as they indicate secondary infections. These measures work well because early indications of secondary include, a fever, low blood pressure and in some cases with elderly patients, decreased mental status. Whenever a hospital RN identifies one of these measures, they can then notify the attending physician to make an appropriate diagnosis. Diagnosing and investigating patterns of nosocomial infections are extremely important for hospitals, especially in relation to their high-risk patients. Regardless of if a single patient develops a nosocomial infection or there is an unlikely outbreak of disease with the hospital, the potential danger is high. However, the capability that the lab has within the hospital will readily assist with identifying these patterns of illness. Labs are able to conduct blood counts, blood cultures and urine cultures, which will help identify the presence of infection if there is a high WBC count, or identify the microorganism causing the illness. Aside from the lab, technicians such as X-ray technicians can assist in the early identification of pneumonia in ventilator-assisted patients or those with a medical history, which may make them more susceptible to illness. One practice, which came about, in the early 2000’s, is the use of infection control practitioners (CDC, 2000). Not only in the United States, but as well as in other countries the use of such practitioners could prove helpful in assessing nosocomial infections earlier rather than later. Infection control practitioners are typically RN’s, microbiologists or epidemiologists who identify problems and collect data in an effort to prevent infections and improve patient safety (CDC, 2000). Researchers have found that these practitioners should be present in every hospital, stating in the results of their study that at least infection control practitioner per every 250 patient beds is necessity (CDC, 2000).

Policy Development:
The next part of the core functions and essential services is that of policy development, which includes: inform, educate, empower, mobilizing of community partnership and the development of policies. Informing and educating high-risk patients and their families early on in their hospital stay is essential. If a patient is able to care for himself or herself, providing them with information in regards to cleanliness is important in decreasing their chances of acquiring a secondary infection. The same is true with the patient’s family since they have access to illness outside of the hospital, as well as in other parts of the hospital. Educating patients on lifestyle changes, such as diet, exercise, and smoking they can make in an attempt to improve their overall health will also attribute to decreasing nosocomial infections. If a patient can quit smoking, improve blood pressure or control diabetes, then they are significantly reducing their chances of hospitalization. This education pairs well with mobilizing community partnerships. If the hospital can implement a community health and wellness program, or a mini education series aimed at improving health, then the potential to reduce high-risk patient hospitalization is present and could potentially lead to a reduction in nosocomial infections. The most significant aspect of policy development is developing policies in regards to hospital-acquired infections. Policy development must be done by each individual hospital, and though globally the policies may be similar, it is the reinforcement of such policies that will aim to prevent hospital-acquired infections. These policies include promoting proper and frequent handwashing techniques, as well as precautions with glove use. Another major policy that hospitals must increase in is isolation precautions and proper preparation of patients who will undergo invasive procedures. Without reinforcement of these policies, nosocomial infections will only continue to rise and have the potential to become an epidemic. However, most of these policies are already a general rule of practice, but having goals or objectives to meet as an individual hospital will provide proper incentive to reduce the number of infections, and this implementation starts with the administration and likely the infection control practitioners. If a hospital were to calculate the number of nosocomial infections treated per month and set a monthly goal of reduction, that is a step in the right direction in an effort to decrease infection. With all of this being said, nosocomial infections are inevitable, but are currently the leading cause of preventable illness and death and any attempt to educate patients or reinforce hospital policies is an attempt to decrease rising numbers.

Assurance:
Assurance, as a part of the core functions and essential services, contains enforcement of laws, link to/provide care, the assurance of a competent workforce and evaluation of current practice. The enforcement of laws in hospitals around the world is of absolute value. There is a broad array of regulations, which fall under the category of law enforcement, as well as the quality of care given. Hospitals do a fairly decent job of complying with regulations such as water supply, waste disposal and sterilization, but that is not to say, there is not room for improvement. These regulations, which may not even be present in developing countries, are a key beginning in reducing the risk of nosocomial infections. Another law that may be looked over is that of hazard investigation. When these infections occur, causation is not always identified, and setting a quarterly goal of looking into hazard investigation may help tremendously. If hospitals can take a look at the most common nosocomial infections and define the cause, they may be able to see if there is something within a department, causing these patients to acquire secondary infections. Similarly, all hospitals should take part in the voluntary program set up by the Centers for Disease Control and Prevention (CDC) known as the Nosocomial Infections Surveillance System (NNIS) (CDC NNIS System, 2003). This system was set up in the early 1970’s in an attempt to assess what may be causing such high incidences of nosocomial infections. What the system does is provide a set of standardized protocols, which they define as surveillance components. These components include adult and pediatric ICU, high-risk nursery (HRN) and surgical patients (CDC NNIS System, 2003). Each hospital looks at the number of patients at risk, the number of days spent as an inpatient and the number of days for which a catheter or central line is placed if applicable (CDC NNIS System, 2003). Then, if a nosocomial infection is developed, the data may be taken, coupled with CDC guidelines, as well as the lab and clinical data to find correlations (CDC NNIS System, 2003). The one I found particularly interesting was in relation to surgical patients. Hospitals who participate in NNIS will categorize all surgical patients by procedure, identify any underlying risk factors and then evaluate their risk factor on a scale to determine who is more likely to develop infection (CDC NNIS System, 2003). If the NNIS was something all hospitals required, rather than being voluntary, the trends could be followed over time and eventually lead to the development of preventative measures.

Link to/provide care is something that can be directly incorporated with the identification of the population under assessment, as well as within inform, educate and empower portion under policy development. The ability of a hospital to relate to the patients they are providing care and their willingness to help them outside of the hospital could be extremely beneficial, especially in the case of invasive procedures or wound care. If a patient presents to the hospital for wound care, there is great potential for developing a staph infection during their stay. However, it is unlikely their wound will be 100% cured upon discharge, and they may fall under the acquiring of infection a few days after discharge. This is where outpatient wound care is important, because, if a hospital knows they cater to a low-income population or those who rely on others for transportation, it may be wise to provide a transportation service to such a clinic. They may also provide some materials free of charge that will help patients take care of themselves at home. Hospitals, in general, have a wealth of knowledge and resources they can provide to their population and with prevention of worsening infections, such a link is vital.

Assurance of a competent workforce:
The quality of care provided is key causative factors in relation to nosocomial infections. Aside from surveillance of infections, quality of care has direct correlation to those who provide care, i.e. nurses, physicians, physician assistants, nurse practitioners and all other hospital staff. The competency of such workers is assumed considering licensing boards require those providing direct patient care go through years of school and pass a multitude of tests. However, once in the workforce, many of the essential measures in the form of quality of care can be overlooked. Providing all staff regardless of the department with guidelines of expectations upon hire and testing on such guidelines will help reaffirm that the hospital takes quality of care seriously. Aside from that, posting these guidelines in break rooms or lounges could provide reaffirming knowledge on a daily basis. Something that could be looked into further would be the possibility of routine, random checks where a quality official follows staff without notice, so they are able to see first hand that up to par quality of care is being provided all around from cleanliness to patient interaction. If it is found that any member of the staff is non-compliant in even the most minor aspect, the hospital could require a training session or have a warning system that limits the number of times you can be found at fault. Overall, quality of care is the key. Patients surrounded by proper, sterile methods, appropriate attention, strictly enforced quality control measures are less likely to obtain a nosocomial infection, therefore, over time hospitals should readily see a decrease in the number of nosocomial infections. Lastly, the evaluation of all measures put into place will allow the hospital to see where they still need to develop and if certain methods are ineffective. Through this evaluation, hospitals are able to see the effectiveness of infection control practitioners, the NNIS program, and the quality of care measures implemented. To begin this evaluation, hospitals may ask themselves questions specifically along the lines of are we seeing a decrease in the number of nosocomial infections? Are our patients getting the best quality of care? Are we providing the proper education and incentives? If they answer any of these questions no, they would seek further knowledge into why and see if they should discard what they are doing and create something new, or if they just need to improve more on current policy and action.

Research:
Through all nine of the essential services, hospitals are able to gain substantial knowledge on nosocomial infections within their facilities. Continuing research into causative factors and quality of care will always be important, and is something hospitals should never halt. They can, however, look for innovative ways to improve the quality of care as the years go on and medicine evolves, as well as research into possible medications, which may provide a more rapid treatment for hospital-acquired infections. In my opinion, the more research a hospital can do and the more up to date they can stay, the more effort they are putting into decreasing highly preventable illnesses.

Assignment 3: Epidemiology and Biostatistics

Identify three to five key points/ideas from the readings and modules related to Epidemiology and Biostatistics and explain how each point/idea has contributed to your understanding of these concentration’s roles in your selected public health issue.

The field of epidemiology assesses trends, patterns and concerns relevant to health within a population. Hospital-acquired infections occur within all hospitals globally, and epidemiological data serves as a basis for being able to understand this issue. While nosocomial infections are an endemic, individual hospitals are likely to have a different infection that is most prevalent. In an effort to gain information and understand the various infections occurring, it is appropriate that each hospital begin with an observation process. Hospitals can start by observing their high-risk patients, specifically within the ICU, NICU and inpatient surgery departments where the rate of acquiring secondary infections is higher. The hospital may look at age, underlying medical conditions, and if such factors will potentially play a role in the patient’s current illness, in turn affecting their risk of acquiring an infection. Hospitals may also observe this inversely, looking at the treatment provided by the medical staff in terms of frequent, proper care and if sanitation practices are consistent with hospital policy. The origin of health issues within populations is also a key focus of epidemiology. The ability of the hospital to identify the root causes for nosocomial infections is essential in order to create the necessary prevention measures. If the hospital can readily identify infections by department and type, as well as define patients' underlying medical conditions and the extent of their current condition, the opportunity to obtain the origin is accessible. Though time consuming, identification of the underlying cause of a nosocomial infection is within the hospitals control. Hospitals are able to prevent unsanitary practice or inadequate treatment by medical personnel, and opportunities to implement practical, reasonable measures that provide solutions to the problem are present. Biostatistics focuses on providing information on a population's health through the use of statistical data for interpretation. Biostatistics is valuable in terms of hospital-acquired infections and may be applied in various ways. One can first identify the total number of patients within a given hospital who acquire a nosocomial infection and further analyze that data to obtain relevant information. The total number of patients found may be broken down into multiple statistical categories such as the percentage of acquired infections by department, the percentage of infections acquired by type and of those, and which secondary infection is the most common. Interpretation of survival rate and mortality rate for all patients who acquire an infection within individual hospitals respectively is another vital way statistics may be used. Globally, obtaining biostatistics within hospitals allows facilities to benchmark their numbers against other facilities, as well as analyze trends over time, further allowing determination of how hospital-acquired infections differentiate amongst populations.

Provide two concrete examples, from peer-reviewed journal articles, that demonstrate Epidemiology and Biostatistics contribution to your public health issue.

In the Annals of Internal Medicine, a peer-reviewed article focused on the Epidemiology of Nosocomial Infections Caused by Methicillin-Resistant Staphylococcus aureus. This study readily identified the elevation in hospital-acquired infections caused by Methicillin-Resistant Staphylococcus aureus, and the need to determine the reasoning behind this increase. The study used epidemiology through the creation of three methods that used monitoring techniques as their basis in identification. The three observation method included daily clinical laboratory surveillance, monthly prospective microbiologic surveys of high-risk inpatients, as well the recognition of previously infected or colonized patients at rehospitalization (Robinson, R. L., Ignacio, C. M., & Wenzel, R. P. 1982). Through the use of these surveillance techniques, researchers are able to gain proper knowledge in terms of finding the origin of infection within each appropriate process, or if there is a commonality between them. Biostatistics was particularly evident in the peer-reviewed journal article titled Major trends in the microbial etiology of nosocomial infections. Aside from determining the number of patients and the percentage of patients who acquire infections, biostatistics may be used to assess trends over time relative to individual nosocomial infections. This study found a 7% reduction in E. coli infections over a six-year period, a 2% decrease in K. pneumoniae, a 5% increase in coagulase negative staphylococci, and a 3% increase in C. albicans (Schaberg, D. R., Culver, D. H., & Gaynes, R. P. 1991). Researchers used this data, contrasting it to the changes seen in the decade before and found that though there were decreases in many infections, the infections which increased were due to pathogens that had increased resistance, and were not as easy to treat as those infections which saw decreases (Schaberg, D. R., Culver, D. H., & Gaynes, R. P. 1991).

Explain how these examples contribute to your understanding of your selected public health issue. These examples provided an illustrative example of how epidemiology and biostatistics may be used as a basis for problem solving in relation to hospital-acquired infections. Rather than recognizing infections by the hospital or state, the epidemiological portion of this study focused on providing a solution to an increasing national trend in regards to hospital-acquired infections. Secondary infections cannot be seen, nor predicted and the use of various monitoring methods contributed to understanding the importance of identifying and observing the most significant factors in relation to infection type. Without epidemiologic monitoring or observation, the chances of identifying the most prevalent infections, or their origin would decrease significantly and not allow for proper policy implementation. Biostatistics is an excellent resource in terms of understanding infections trends over time. This example in particular was relevant because it showed both increasing and decreasing trends for multiple infections. While a reduction in any hospital-acquired infection is good, the statistical interpretation of the increase is necessary. The statistical increase found within this study is reliable, numeric proof that the pathogens, which are becoming more common over time, are resistant to common treatments and, therefore, a feasible solution, must begin to be implemented sooner rather than later.

Explain the process used to identify these examples

To obtain these examples, I first looked at the modules provided, as well as the notes I took during our discussion group on obesity, which had a similar foundation. After recollection of the discussion, I thought about what I’d like to talk about and the types of articles that really help me understand my topic in terms of epidemiology and biostatistics. I then went to JSTOR and Google Scholar using the topics: observation of hospital-acquired infections and statistics on hospital-acquired infections. I was then able to search through a variety of articles and find ones, which afforded me, true understanding.

Explain the potential role of Epidemiology and Biostatistics in developing and/or designing an intervention to address your selected public health issue.

Epidemiology and Biostatistics play a vital role in developing interventions in terms of nosocomial infections. Epidemiology within each hospital will focus on observation and origin in terms of the most prevalent infections and their cause, the patients that are acquiring these infections in terms of medical history and current maladies, as well as the precautions medical providers are practicing. The identification of such data is the first step in determining the course of action the hospital must take in developing or designing an intervention. Biostatistics is of the utmost importance because it allows hospitals to recognize how they fair from a national standpoint, as well as how they are doing over time (are infections increasing or decreasing and why) which is substantial information in terms of determining the magnitude of the problems and the success of interventions that may be implemented.

Assignment 4: Environmental and Occupational Health

Identify three to five key points/ideas from the readings and modules related to Environmental and Occupational Health and explain how each point/idea has contributed to your understanding of these concentration’s roles in your selected public health issue.

Genetic, physiologic and psychosocial factors that affect susceptibility to adverse health outcomes following exposure to environmental hazards When dealing with nosocomial infections on a global level it is important to understand that the environment surrounding the patient and health care provider influences the outcome of nosocomial infections. If an area has less access to healthy foods, and exercise is not promoted, the hospital may have patients with more underlying illnesses aside from their current ailment, than an area with greater access to such things. Therefore, if there is prolonged hospitalization or the need for continued care after discharge, the chances of obtaining a hospital acquired infection increase. Hospitals in this predicament may have a higher mortality rate because it can become significantly more difficulty to overcome a nosocomial infection with underlying disease, thus genetic, physiologic and psychosocial factors are important in understanding how susceptible each patient is in obtaining a disease. Another factor to help identify susceptibility is through income of either the patient, or average income of the area the hospital is in. Knowing whether or not hospitals in low-income areas are able to provide the same treatment following exposure as an upper class area affords insight into what the overall outcome may be.

Federal and state regulatory programs, guidelines and authorities that control environmental health issues Federal and state regulatory programs, as well as guidelines are crucial to understanding, and preventing hospital acquired infections. The authorities involved at the federal and state level provide a link between the patient and healthcare facility, therefore providing the most control in prevention of hospital acquired infections. In terms of environmental health, regulations on clean air and clean water, as well as regulations when building the hospital or treatment facility help to provide prevention both during admission, as well as upon discharge. Occupational health regulations have the potential to provide the greatest impact on nosocomial infections. Guidelines in regards to handwashing and changing of gloves after each exposure with patients aids in not only quality of patient care and prevention measures, but as well as provider safety. Other occupational health guidelines implemented include protective gear such as masks and disposable gowns when dealing with patients who have or will undergo an invasive procedure. As a whole however, there are no mandatory regulatory programs that require hospitals to report nosocomial infection data. Especially at the state level, it is important for regulations to be put in place in terms of publicly reporting all data, and gathering it in a standardized way. This will help authorities at all levels determine the steps that must be taken to aid in reducing the number of acquired infections.

Approaches for assessing, preventing and controlling environmental hazards that pose risks to human health and safety in both urban and rural settings Regardless of urban or rural setting, assessing nosocomial infections is the first step in being able to prevent and control them. It would be extremely time consuming and likely take years to figure out how to control all nosocomial infections within every hospital, but assessing the main infections could be a starting point. Once a hospital has readily identified its primary infections, standardized ways of collecting data could be implemented. Gathering this data over time allows preventative measures to be taken and also has the potential to allow guidelines or regulations to be put into place in an effort to control nosocomial infections both during admission and upon discharge.

Provide two concrete examples, from peer-reviewed journal articles, that demonstrate Environmental and Occupational Health’s contribution to your public health issue. A worldwide study was done in 2011 on the socioeconomic impact on device-associated infections in pediatric intensive care units in 16 countries (Rosenthal, Jarvis, Jamulitrat, Silva & Ramachandra, 2011). For five years, the study followed 33 pediatric ICU’s, comparing results of public versus private hospitals and the income of the country relative to infection rates. The study looked at the three most common hospital-acquired infections: central-line associated bloodstream infection rates, catheter-associated infection rate and ventilator-assisted pneumonia. What was shown was that for all three infections, lower-middle income countries had significantly higher rates of infection per 1000 days than low-income countries and upper-middle income countries (Rosenthal, Jarvis, Jamulitrat, Silva & Ramachandra, 2011). Overall, the study found that the type of hospital, as well as the socioeconomic level of the country played a factor in acquiring a device-associated nosocomial infection and the numbers should be considered when comparing countries (Rosenthal, Jarvis, Jamulitrat, Silva & Ramachandra, 2011). Another study done focused on the significance of handwashing in the hospital environment and the impact it has on nosocomial infections, using a before and after effect. The study specifically looked at Methicillin-resistant Staphylococcus aureus (MRSA) and the compliance of health care workers with hand hygiene and alcohol-based hand rub practices (Allegranzi & Pittet, 2009). Over a year, the study implemented a surveillance program that assessed patient care during pre and post periods of treatment, in an effort to identify risk factors. During the first year, the study observed 1,531 opportunities to use hand hygiene practice during pre and post periods, whereas in the second year, only 450 opportunities were observed (Allegranzi & Pittet, 2009). This was a significant increase from 54.3% compliance with handwashing to 75.8% compliance (Allegranzi & Pittet, 2009). This improvement also coupled with a steady increase in the use of alcohol-based hand rub practice after results were given. Overall, once these procedures improved, the study found that new hospital-acquired MRSA was reduced, specifically in the post intervention time period (Allegranzi & Pittet, 2009).

Explain how these examples contribute to your understanding of your selected public health issue
The first study is important in understanding that just looking at hospitals rates will not be sufficient in implementing preventative measures. Understanding the type of environment the patients are being surrounded by, as well as the resources the personnel have available to them are important factors in preventing and controlling nosocomial infections. The second study provides an understanding of how important regulation and guidelines are in preventing infection, as well as how vital compliance is. Overall, the examples help to understand nosocomial infections by identifying the methods used to study environmental and occupational health.

Explain the process used to identify these examples
To obtain these examples, I first looked at the modules provided and decided what I should focus on in regards to my topic and the selected concentration. I then went to JSTOR and Google Scholar to research articles specific to Environmental and Occupational Health. I was then able to search through a variety of articles and find ones, which afforded me, true understanding. Explain the potential role of Environmental and Occupational Health in developing and/or designing an intervention to address your selected public health issue. Environmental and Occupational health play a key role in designing an intervention in regards to hospital-acquired infections. The most important intervention for hospital-acquired infections is the design of mandatory, standardized programs that make hospitals report data both regarding the patient and their illness, as well as about health providers and sanitary practices. For such an intervention, environmental health will not only regulate things such as air and water, but will also continue to provide information on the types of patients a particular hospital may see and their lifestyle choices. These key topics found within environmental health provide a platform for how occupational health may reduce nosocomial infections. With all of that information known, health professionals are then able to identify their high-risk patient pool and assure that they are complying with all policies in regards to patient contact. Together, both environmental and occupational health have the power to create state, national and global regulations in regards to gathering and reporting data, safer practice measures and potentially controlling outbreaks of nosocomial infections.

References
Allegranzi, B., & Pittet, D. C. (2009). Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection, 73(4), 305-315. Retrieved from http://www.sciencedirect.com/science/article/pii/S0195670109001868
Braun, B., Carr, M., & Cheng, A. (2004). An approach to the evaluation of quality indicators of the outcome of care in hospitalized patients, with a focus on nosocomial infection indicators. American Journal of Infection Control, 23(3). Retrieved from http://www.ajicjournal.org/article/0196-6553(95)90045-4/references CDC (2003). National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 to June 2003, issued August 2003. Am J Infect Control 2003;31:481-98. Retrieved on September 20, 2013, from http://www.cdc.gov/nhsn/pdfs/datastat/nnis_2004.pdf CDC. (2000). Public health focus: surveillance, prevention and control of nosocomial infections. MMWR, 48, 8th ser., 149-153. Retrieved September 20, 2013, from 1992;41:783-7. Retrieved on September 20, 2013, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4908a1.htm
Healthcare associated infections fact sheet. (n.d.). World Health Organization Patient Safety. Retrieved September 04, 2013, from http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
Inwegbu, K., Dave, J., & Pittard, A. (2005). Nosocomial infections. Oxford Journal, 5(1), 14-17. Retrieved September 04, 2013, from ceaccp.oxfordjournals.org/content/5/1/14.full
Peterson, A., & Walker, P. (2006). Hospital acquired infections as patient safety indicators. Annual Review of Nursing Research, 24, 75-99. Retrieved September 04, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/17078411
Roberts, R., Scott, D., Cordell, R., Solomon, S., Steele, L., Kampe, L., ... Weinstein, R. (2003). The use of economic modeling to determine the hospital costs associate with nosocomial infections. Oxford Journal, 36(11), 1424-1432. Retrieved September 04, 2013, from http://cid.oxfordjournals.org/content/36/11/1424.full
Robinson, R. L., Ignacio, C. M., & Wenzel, R. P. (1982). Epidemiology of Nosocomial Infections Caused by Methicillin-Resistant Staphylococcus aureus. Annals of Internal Medicine, 97(3), 309-317. Retrieved October 11, 2013, from http://annals.org/article.aspx?articleid=695856
Rosenthal, V. D., Jarvis, W. R., Jamulitrat, S., Silva, C. R., & Ramachandra, B. (2011). Socioeconomic impact on device-associated infections in pediatric intensive care units of 16 limited-resource countries: International nosocomial infection control consortium findings. Pediatric Critical Care Medicine, 13(4), 399-406. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22596065
Schaberg, D. R., Culver, D. H., & Gaynes, R. P. (1991). Major trends in the microbial etiology of nosocomial infection. The American Journal of Medicine, 91(3), 72-75. Retrieved October 11, 2013, from http://www.sciencedirect.com/science/article/pii/000293439190346Y
Zaidi, A., Huskins, C., Thaver, D., Bhutta, Z., Abbas, Z., & Goldmann, D. (2008).
Hospital-acquired neonatal infections in developing countries [Abstract]. Journal of Hospital Infection, 68(4), 285-292. Retrieved September 04, 2013, from http://www.sciencedirect.com/science/article/pii/S019567010800011X

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