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How Hospitals Can Reduce Hospital-Acquired Infections

The infection prevention and control program can implement elements to reduce the number of these infections. The elements are not to be done by the program exclusively, but in conjunction with other hospital departments:

  • Develop a highly visible and administratively supported infection prevention and control program with qualified and trained personnel.

  • Promote compliance with ongoing monitoring of hand hygiene protocols.

  • Provide competency-based training program for:

    • insertion and maintenance of urinary catheters

    • insertion and maintenance of central venous catheters and IVs, including interventional radiology and the cardiac catheterization laboratory

    • all personnel who provide respiratory therapy for ventilated patients

    • all personnel who prepare and/or administer injections and parenteral infusions

  • Implement a surgical care improvement program for:

    • appropriate prophylactic antibiotic use

    • adherence to preoperative surgical scrub and hand hygiene, use of surgical attire and drapes, aseptic technique and sterile field, cleaning and disinfection of environmental surfaces, minimal traffic in Operating Room (OR)

    • periodic operating room observations and interaction with staff

  • Adhere to recommended infection control practices for C. difficile infection prevention:

    • adherence to hand hygiene with soap and water

    • appropriate use of PPE

    • compliance with contact precautions (or your institution’s variation, e.g. special contact or enhanced precautions)

    • adherence to cleaning and disinfection procedures (e.g. bleach disinfection)

  • Maintain an active, concurrent surveillance program:

    • monitor HAIs and epidemiologically important organisms (e.g., CRE)

    • analyze data to determine if corrective action is needed

    • report information back to staff on a regular basis

  • Adhere to transmission-based precautions.

  • Implement an effective, multidiscplinary antibiotic stewardship program.

  • Interact with Environmental Services and ensure training is provided to all personnel who clean and disinfect patient areas.

  • Collaborate with the Sterile Processing Department (SPD) to ensure they have trained personnel and follow AAMI standards for reprocessing instruments.

  • Ensure that scope reprocessing is done appropriately.

To help facilities reduce hospital-acquired infections, the Centers for Disease Control and Prevention (CDC) has instituted a new strategy to prevent healthcare-associated infections , called the Targeted Assessment for Prevention (TAP).TAP uses data to initiate action to prevent these infections and targets healthcare facilities and specific units within facilities with a disproportionate burden of HAIs so that gaps in infection prevention in the targeted locations can be addressed. The TAP report allows ranking of facilities, or locations within individual facilities, to prioritize prevention efforts where they will have their greatest impact. Data used for TAP are reported by healthcare facilities to CDC’s National Healthcare Safety Network (NHSN). Healthcare facilities may use their own data to generate TAP reports for different infections and patient care locations.

The CDC also provides assessment tools to help you monitor the multiple facets of your program.2

However, none of these recommendations can be done in a vacuum. Infection preventionists (IPs) need to have physician, nursing, and administrative champions to help achieve their goals. For the elements that require training, it is not one and done – training should be provided upon hire, annually, and if new instrumentation or products are used.

Does your facility have an education department that is adequately staffed to provide education to all of the staff? What are your greatest challenges in reducing hospital-acquired infections?


  1. Centers for Disease Control and Prevention. Healthcare-Associated Infections. The Five “W’s of the Targeted Assessment for Prevention (TAP) Strategy. Cited January 4, 2015:

  2. Centers for Disease Control and Prevention. Healthcare-Associated Infections. Infection Control Assessment Tools. Cited January 4, 2015:

How to Build a High-Performing Infection Prevention and Control Program. Download eBook now.

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Written for clinicians

by clinicians.