The Best Hospital Practices for Controlling Methicillin‐Resistant Staphylococcus aureus : Onthe Cutting Edge • Author(s): Meredith S. Arnold , BSN, CIC; Jane M. Dempsey , MS, CIC; Marlene Fishman ,MPH, CIC; Patricia J. McAuley , RN, BSN; Cynthia Tibert , BSN, CIC; Nancy C. Vallande ,MSM, CICSource: Infection Control and Hospital Epidemiology, Vol. 23, No. 2 (February 2002), pp. 69-76Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/502009 .

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Vol. 23 No. 2 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY 69

THE BEST HOSPITAL PRACTICES FOR CONTROLLING

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS:ON THE CUTTING EDGE

Meredith S. Arnold, BSN, CIC; Jane M. Dempsey, MS, CIC; Marlene Fishman, MPH, CIC; Patricia J. McAuley, RN, BSN; Cynthia Tibert, BSN, CIC; Nancy C. Vallande, MSM, CIC

OBJECTIVE: A performance improvement task force ofRhode Island infection control professionals was created to devel-op an epidemiologic model of statewide consistent infection con-trol practices that could reduce the spread of methicillin-resistantStaphylococcus aureus (MRSA).

DESIGN: This model encompasses screening protocols,isolation techniques, methods of cohorting positive patients, decol-onization issues, postexposure follow-up, microbiology proce-dures, and standardized surveillance methodologies. These “bestpractice guidelines” include three categories of recommendationsthat define priority levels based on the availability of scientific data.

SETTING: From 1995 through 2000, several Rhode Islandhospitals experienced a fivefold increase in nosocomial acquisitionof MRSA.

PARTICIPANTS: Rhode Island infection control profes-sionals are a highly interactive group in the unique position ofsharing patients and ultimately experiencing similar trends andproblems.

INTERVENTION: The task force collaborated on develop-ing the best hospital infection control practices to prevent and con-trol the spread of MRSA in Rhode Island.

RESULTS: The task force met with local infectious diseasephysicians and representatives from the Rhode Island Departmentof Health, the Hospital Association of Rhode Island, and RhodeIsland Quality Improvement Partners. Discussions identifiednumerous and diverse MRSA control practices, issues of consen-sus, and approaches to resolving controversial methods of reduc-ing the spread of MRSA. The guidelines regarding the best hospi-tal practices for controlling MRSA were finalized 8 months later.

CONCLUSION: These guidelines were distributed to allchief executive officers of Rhode Island hospitals by the RhodeIsland Department of Health in December 2001. They were issuedseparate and apart from any regulations, with the intent that hos-pitals will adopt them as best hospital practices in an attempt tocontrol MRSA (Infect Control Hosp Epidemiol 2002;23:69-76).

In Rhode Island, infection control professionals are ahighly interactive group in the unique position of sharingpatients and ultimately experiencing similar trends andproblems.

At the local meeting of the Infection ControlProfessionals of Southern New England (ICP-SNE), a hos-pital in Rhode Island reported a change in the susceptibil-ity of its methicillin-resistant Staphylococcus aureus(MRSA) to vancomycin. This initiated further discussionand the development of a survey tool that was distributedto ICP-SNE members to assess current MRSA control pro-tocols. The results showed inconsistent practices. In addi-tion, diverse practices for MRSA surveillance were identi-fied.

METHODS

Representatives from 5 of the larger acute-care hospitals met with the goal of standardizing MRSAinfection control practices such as surveillancemethodologies,1-5 screening protocols,4,6-17 isolation tech-niques,1,3,6,8,15,17-23 cohorting of positive patients,18 decolo-nizing patients who have MRSA,1,8,10,16,22,24,25 and postexpo-sure follow-up protocols.8,18 This task force began by standardizing surveillance methods. They compiled noso-comial MRSA acquisition rates calculated by patient-days.The aggregate data demonstrated a greater than fivefoldincrease from fiscal year 1995 to 2001 (Figure). The taskforce then drafted a preliminary set of guidelines that wasbased on a review of current scientific literature.26-39 Local

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Ms. Arnold and Ms. McAuley are from Kent Hospital, Warwick, Rhode Island. Ms. Dempsey is from Rhode Island Hospital, Providence, RhodeIsland. Ms. Fishman is from St. Joseph Health Services of Rhode Island, North Providence, Rhode Island. Ms. Tibert is from Veterans’ AdministrationHospital, Providence, Rhode Island. Ms. Vallande is from Miriam Hospital, Providence, Rhode Island.

Address reprint requests to Marlene Fishman, MPH, CIC, Infection Control Director, Marian Hall, First Floor, Our Lady of Fatima Hospital, 200High Service Avenue, North Providence, RI 02904.

Developed and sponsored by a task force of the Infection Control Professionals of Southern New England (ICP-SNE) in cooperation with InfectiousDisease Physicians from Rhode Island, and in collaboration with representatives from the Rhode Island Department of Health (HEALTH), the HospitalAssociation of Rhode Island (HARI), and Rhode Island Quality Improvement Partners.

The authors thank Leonard A. Mermel, DO, ScM, for lending his expertise during the development of the guidelines and Eileen Brennan for prepar-ing the manuscript.

Presented as an abstract at the Department of Veterans’ Affairs National Occupational Health and Safety Conference; August 2001.

ABSTRACT

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70 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY February 2002

unpublished data were also used. A priority level wasassigned to each recommendation. Next, the task forceobtained input from local infectious disease physicians, andapproached the Hospital Association of Rhode Island(HARI), the Rhode Island Department of Health(HEALTH), and Rhode Island Quality ImprovementPartners to assist with development of the document“Methicillin-Resistant Staphylococcus aureus (MRSA): BestPractice Guidelines for Hospitals.”

RESULTS

The guidelines below were issued by the RhodeIsland Department of Health, separate and apart from anyregulations. A glossary for these guidelines appears at theend of this article.

Methicillin-Resistant Staphylococcus aureus (MRSA):Best Practice Guidelines for HospitalsSeptember 5, 2001Introduction:

These guidelines are established in response toand recognition of recent nationwide increases in noso-comial acquisition of methicillin-resistant Staphylococcusaureus (MRSA). A performance improvement task forceof Rhode Island infection control professionals was creat-

ed to develop an epidemiological model of statewide con-sistent infection control practices that could reduce thespread of MRSA. This model encompasses screeningprotocols, isolation techniques, methods of cohorting pos-itive patients, decolonization issues, postexposure follow-up, microbiology procedures, and standardized surveil-lance methodologies. These “Best Practice Guidelines”include three (3) categories of recommendations (LevelsI, II, and III) that define priority levels based on availabili-ty of scientific data. The guidelines are sanctioned by thelocal infection control and infectious disease communityand the Rhode Island Department of Health.

Definitions of Priority Levels:Priority Level I—Strongly recommended and

strongly supported by well-designed epidemiologicalstudies and experience.

Priority Level II—Highly recommended andviewed as effective by experts in the field, and supportedby strong rationale and suggestive evidence.

Priority Level III—Moderately recommended;should be considered based on theoretical risk and sup-ported by limited studies involving innovative approachesto infection control interventions.

Note: Priority levels are listed after each prac-tice. In some instances, there may be choices of pri-ority levels. Decisions should be made, dependent onindividual facility approaches to the control of MRSA.

Best Practices for Hospitals:

I. SCREENING PROTOCOLS—for identification ofpatients at risk of having MRSA

A. Candidates for screening—Refer to Tables I and II.1. Long term care facility residents, within 24–48

hours of admission to hospital. [Level I]2. Patients from other acute care facilities, within

24–48 hours of admission. [Level I]3. Admissions to rehabilitation units (facilities),

within 24–48 hours of admission. [Level I]

TABLE ISCREENING PROTOCOLS FOR IDENTIFICATION OF PATIENTS WITH METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Who When Site(s) Priority Level

LTCF residents 24–48 hrs of admission Nares, draining wounds I

Patients from other acute-care facilities 24–48 hrs of admission Nares I

Draining wounds II

Admissions to rehabilitation units 24–48 hrs of admission Nares I

Draining wounds II

Dialysis patients 24–48 hrs of admission Nares I

Draining wounds II

Readmitted patients � 30 days since 24–48 hrs of admission Nares I

previous hospital discharge

LTCF = long-term–care facility.

FIGURE. Aggregate graph of nosocomial methicillin-resistant Staphylococcusaureus (MRSA) rates.

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Vol. 23 No. 2 BEST HOSPITAL MRSA CONTROL PRACTICES 71

4. Renal (dialysis) patients, within 24–48 hours ofadmission. [Level I]

5. Re-admissions to the hospital � 30 days of pre-vious discharge. [Level I]

6. Periodic prevalence studies of admissionsand/or transfers to and discharges from an intensive careunit (ICU). [Level I]

7. Periodic prevalence studies of preoperativepatients.

a. Those having major surgical procedures toinclude: [Level III]

● Vascular procedures● Orthopedic procedures● Cardiac/thoracic procedures● Neurosurgical procedures

b. Screen preoperative patients if MRSA isknown to be a causative agent among major surgical pro-cedures [Level I]

8. Consider gathering baseline data to study:a. Residents of assisted living facilities with-

in 24–48 hours of admission to the hospital. [Level III]b. Residents of group homes within 24–48

hours of admission to the hospital. [Level III]B. Screening cultures (anatomical sites)—Refer to

Table I.1. Recommendations for long term care resi-

dents and patients transferred from other acute carefacilities (hospitals)

● Bilateral anterior nares, utilizing one (1)culturette for both nares. (Minimum requirement forscreening.) [Level I]

● Any open skin lesions, draining wounds, toinclude surgical sites, when noted on admission to thehospital. [Level I]

2. Recommendations for admissions to rehabili-tation units (facilities)

● Bilateral anterior nares [Level I]● Draining wounds [Level II]

3. Recommendations for renal (dialysis) patients● Bilateral anterior nares [Level I]● Draining wounds [Level II]

4. Recommendations for re-admitted patients ��30 days since previous discharge

● Bilateral anterior nares [Level I]C. Periodic prevalence studies (anatomical sites)—

Refer to Table II1. Recommendations for admissions and/or

transfers to and discharges from an ICU● Bilateral anterior nares (minimum require-

ment for screening) [Level I]● Sputum, in the presence of productive

cough and/or suctioning [Level II]2. Recommendation for preoperative patients,

patients from assisted living facilities, and patientsfrom group homes [Level III]

● Bilateral anterior nares2a. If MRSA is known to be a causative agent

among identified surgical procedures, screen (nares cul-ture) preoperative patients. [Level I]

3. Recommendations for health care workers(HCWs). (Refer to II. Culturing/Screening Health CareWorkers and Table II) [Level I]

4. Recommendations for patients exposed toother patients who are MRSA positive (Refer to III.Follow-Up for Exposure to Non-Isolated MRSAPositive Patients and Tables II and III) [Level II]

II. CULTURING/SCREENING HEALTH CARE WORK-ERS (HCWs)

A. Do not routinely culture HCWs, as this practice isusually not cost effective. [Level I]

B. Attempts to identify MRSA carriers should be con-

TABLE IIPERIODIC PREVALENCE STUDIES

Who When Site(s) Priority Level

ICU patients Admit/transfer to ICU Nares I

Sputum II

Discharge from ICU Nares I

Sputum II

Preoperative patients (major: orth., Preadmission testing Nares III

card., thoracic, vasc., neuro.) If MRSA is known to be a Nares I

causative agent

Patients from assisted living facilities 24–48 hrs of admission Nares III

Patients from group homes 24–48 hrs of admission Nares III

Healthcare workers During outbreak and/or case Nares I

clusters only, as defined by

biotyping MRSA isolates

Patients exposed to unisolated, See Table III Nares II

unknown MRSA-positive patient

ICU = intensive care unit; MRSA = methicillin-resistant Staphylococcus aureus.

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72 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY February 2002

sidered in the presence of noted outbreaks and/or clus-ters of MRSA positive cultures among patients, as definedby pulsed-field gel electrophoresis or other biotypingmethod. [Level I]

III. FOLLOW-UP FOR EXPOSURE TO NON-ISOLATEDMRSA POSITIVE PATIENTS—Refer to Table III

When a non-isolated patient is identified as having apositive MRSA culture, has been in the hospital � 24hours, and there is a potential for the positive patient tohave exposed other patients to MRSA, a follow-up inves-tigation is indicated. [Level I]

IV. ISOLATION/PRECAUTIONS PRACTICES—Refer toTable IV

A. Category—Contact Precautions, with additionalrequirements for controlling the spread of resistant organ-isms. [Level I]

B. Candidates for Isolation/Precautions1. All patients with MRSA infection, any anatomi-

cal site. [Level I]2. All patients with MRSA colonization, any

anatomical site. [Level I]C. Criteria for practicing appropriate precaution tech-

niques1. Gloves—required for all persons entering the

isolation room/area. [Level I]2a. Gowns—required for all persons providing

direct care and/or having contact with the patient or thepatient’s environment. [Level I]

2b. Gowns—recommended for all personsentering the isolation room/area. [Level II]

3a. Masks—required for all persons entering

the isolation room when MRSA has been found in thepatient’s respiratory secretions (ie, sputum or bron-choscopy specimens), and/or when entering the room ofventilated patients. [Level I]

3b. Masks—recommended for all personsentering the isolation room/area of any MRSA positivepatient. [Level II]

D. Isolation Room1. Private room for all MRSA positive patients,

whether infected or colonized [Level I]a. Exception: De-colonization protocol in use

on patient with MRSA positive nares only. [Unresolvedissue]

2. Patient should be restricted to room, except whenin need of diagnostic or therapeutic services. [Level I]

3. Procedure for patient coming out of isolationroom:

a. Patient must have freshly laundered cloth-ing/gown and must have practiced hand hygiene (Refer toSection E. below) prior to coming out of room. [Level I]

b. Patient wears mask, if sputum positive forMRSA. When patient cannot tolerate a mask, the healthcare worker should wear a mask. [Level I]

orc. Patient wears mask if nares positive

MRSA. [Level III]E. Hand Hygiene

1. The practice of handwashing or application ofalcohol-based, waterless product must be conductedafter caring for a MRSA positive patient. [Level I]

2. Hands must be washed or effectively be treatedwith alcohol-based, waterless product immediately follow-ing removal of gloves. [Level I]

3. Gloves must be removed before leaving roomfollowed by handwashing with antimicrobial soap or awaterless, alcohol-based antiseptic agent. [Level I]

4. Moisturizing hand lotions should be compatiblewith cleansing products and with type(s) of glove materi-als being utilized. [Level II]

F. Visitors of patients on Isolation/Precautions1. Visitors shall wear personal protective attire

while visiting a patient on MRSA precautions and/or whileassisting a patient to walk:

a. Gloves—worn by all visitors. [Level I]b. Mask—if MRSA in the patient’s sputum.

[Level I]c. Gown—if having direct contact with the

patient and/or the patient’s environment. [Level I]ord. Gown—for all entering room regardless of

contact [Level II]2. Visitors should be instructed on removal of per-

sonal protective attire and instructed on handwashingbefore leaving isolation room. [Level I]

G. Transporting MRSA positive patients1. Limit the movement and transport of the patient

from the room to essential diagnostic and/or therapeuticpurposes. [Level I]

TABLE IIIALGORITHM FOR POSTEXPOSURE FOLLOW-UP (LEVEL I)

MRSA = methicillin-resistant Staphylococcus aureus; R/O = rule out.

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Vol. 23 No. 2 BEST HOSPITAL MRSA CONTROL PRACTICES 73

2. The patient should wear freshly laundered attireand if MRSA positive in sputum or nares, wears a surgi-cal mask (if tolerated) during transport. [Level II]

3. Staff members wear regular attire and havegloves available during transport. [Level II]

4. Stretchers are made up with clean linen and pil-low. The patient’s bed linens should not travel with thepatient on the stretcher. [Level I]

V. DECOLONIZATION OF PATIENTSA. Attempts should be made to decolonize patients

with MRSA carriage in the nares only.1. Preoperative patients, at least 24–48 hours

prior to surgery. [Level I]2. All other patients with positive nares. [Level II]3. Patients with MRSA carriage should be bathed

with chlorhexidine or hexachlorophene for 3–5 consecu-tive days, if tolerated. [Level II]

4. Re-culture patient for MRSA carriage no soon-er than 24–48 hours after completion of decolonizationprotocol(s). [Level I]

B. Sites having MRSA colonization other than naresshould not routinely be decolonized. [Level II]

VI. MICROBIOLOGY PROCEDURESA. Cultures to screen for MRSA

1. When screening for MRSA a full culture workup is not necessary. Do oxacillin sensitivity testing onlyto determine presence or absence of MRSA. [Level I]

2. Vancomycin sensitivity testing should be donewhen monitoring resistance trends is indicated. [Level II]

B. Clinical cultures

1. Cultures being processed for a clinical work upshould have full sensitivity testing, as per laboratory pro-tocol. [Level I]

C. Notification of newly positive MRSA cultures1. There should be a procedure for the microbiol-

ogy laboratory to notify the Infection Control Departmentand the inpatient nursing unit/area when a new MRSAisolate is identified. [Level I]

D. Periodic testing for mupirocin sensitivity is recom-mended and encouraged. [Level II]

VII. SURVEILLANCE METHODOLOGIESA. Hospitals should monitor nosocomial MRSA rates

using a denominator of “patient days.” [Level I]B. “Observation days” should be factored into the

patient days denominator when observation patients areheld on inpatient units. [Level I]

C. Nosocomial MRSA rates among patients havingoutpatient services may be monitored using a denomina-tor of “outpatient days.” [Level III]

D. Unit-specific rates of nosocomial MRSA should bemonitored to provide feedback to staff. [Level I]

E. Nosocomial MRSA rates should be evaluatedwhenever feasible according to “infection” versus “colo-nization” with the MRSA organism. [Level II]

F. When a patient is transferred from one hospital toanother, and is identified as MRSA positive, the referringfacility should be notified. [Level I]

VIII. IDENTIFICATION OF PATIENTS KNOWN TO BEMRSA POSITIVE

A. There should be a reliable method of identifying

TABLE IVPERSONAL PROTECTIVE ATTIRE AND PRACTICES FOR ISOLATION/PRECAUTIONS

Who/Activity Gloves Gown Mask Hand Hygiene

HCW Before entering Direct care/contact with If MRSA-positive sputum Before and after

room I patient or environment I and/or on ventilator contact Iwith MRSA I

Before entering room II Before entering room II

Visitors Before entering Direct contact with patient If MRSA-positive sputum Before and after

room I or environment I and/or on ventilator contact Iwith MRSA I

Before entering room II Before entering room II

Patient: walking None I Freshly laundered clothing/ If MRSA-positive sputum Before leaving

or transported gown and linens I and can tolerate mask I room Ioutside room If MRSA-positive nares II

HCW or visitor Available for direct Only for direct patient contact I If MRSA-positive sputum Before and after

with patient, contact I Note: Transporters do not and patient is not masked I contact Ioutside room need gowns to push stretcher/ If patient MRSA-positive nares

wheelchairs. II and patient is not masked III

HCW = healthcare worker; MRSA = methicillin-resistant Staphylococcus aureus.

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74 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY February 2002

previously positive MRSA patients on re-admission to a facility (eg, computer based “flagging” system). [LevelI]

B. Patients may have MRSA flags removed when:1. There is documentation of two consecutive

negative nares cultures and two consecutive negative cul-tures from previously positive site(s). Cultures should betaken no sooner than 48 hours after completion of decol-onization and/or clinical treatment. The two consecutivenegative cultures should be obtained at least 5 daysapart. [Level II]

2. During prolonged hospital stay or upon re-admission, there is documentation of one negative naresculture and one negative culture from previously positivesite(s), obtained 30 days after the noted positive cul-ture(s). [Level III]

IX. DISCONTINUING ISOLATIONA. Patients may come off isolation/precautions proce-

dures when:1. There is documentation of two consecutive

negative nares cultures and two consecutive negativecultures from previously positive site(s). Culturesshould be obtained no sooner than 48 hours aftercompletion of decolonization and/or clinical treatment;consecutive cultures should be at least 5 days apart.[Level II]

2. There is documentation of one negative naresculture and one negative culture from previously positivesite(s) obtained no sooner than 48 hours after completion ofdecolonization and/or clinical treatment. [Unresolvedissue]

X. COHORTING POSITIVE PATIENTSA. It may be necessary to cohort MRSA positive

patients in the same room, when private rooms are notavailable. [Level I]

B. The same isolation/precautions protocols (as out-lined above in IV. Isolation/Precautions Practices) forcohorted patients. [Level I]

C. Patients should be cohorted according to specificcriteria, based on risk or probability of transmission fromone patient to another. [Level I]

XI. OUTPATIENT SERVICESA. Isolation/precautions procedures should be imple-

mented (as in IV. Isolation/Precautions Practices) inoutpatient service areas. [Level I]

B. When feasible, outpatients who are “flagged” asMRSA positive should have procedures/appointmentsscheduled at the end of the work day. [Level III]

C. “Flagged” MRSA positive patients may wait in com-mon waiting areas for outpatient services. [Level III]

DISCUSSION

The increased prevalence of MRSA in hospitals andother healthcare facilities has been recognized as a globalproblem. The guidelines that we have developed have merit

beyond the state of Rhode Island. Their implementation willrequire a cooperative effort. Many discussions were neces-sary before we reached a consensus on specific interventionsthat are needed to control the spread of MRSA.

Our task force agreed that:1. Hospitals should standardize MRSA rates per 1,000

patient-days to track the epidemiology of MRSA in RhodeIsland.

2. Hospitals should monitor nosocomial MRSA ratesand provide feedback to staff.

3. Intensive care units, residents of long-term–care facili-ties, and patients transferred between acute-care facilities arethe greatest reservoirs for MRSA colonization and infection.

4. Hand hygiene practices (ie, hand washing or the useof alcohol-based, waterless products) must be performedafter caring for a patient who is MRSA positive.

5. Contact precautions are necessary for controlling thespread of resistant organisms.

6. A reliable method of identifying previously positiveMRSA patients on readmission to a facility (ie, an electron-ic “flagging” system) should be in place.

Further consideration and more scientific researchare required to answer the following questions:

1. How many repeat screenings are necessary toremove a patient from isolation?

2. Do healthcare workers need to wear a mask whenentering the isolation room of any MRSA-positive patient?

3. Do visitors need to wear personal protective attire?4. Should screening cultures for MRSA include van-

comycin sensitivity testing?5. Can a patient be removed from isolation if he or she is

currently on a decolonization regimen?6. Is there staphylococcal resistance to mupirocin fol-

lowing treatment?7. Should decolonization of patients with MRSA carriage

be attempted?A future goal is to enlist the help of long-term–care

facilities, other healthcare facilities, and outreach pro-grams in developing cohesive and sanctioned MRSA bestpractice guidelines specific to clients served and care pro-vided. A similar task force process could be used to devel-op these guidelines in collaboration with parent organiza-tion(s), the state health department, and infection controlexperts.

We recognize the need to increase the screening ofpatients and to implement consistent guidelines in aneffort to reduce the spread of MRSA. We hope that othercommunities will use these guidelines as a public healthmodel.

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The glossary for the guidelines appears on the next page.

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76 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY February 2002

carrier: a person who harbors a specific pathogenic organism,has no discernible signs and symptoms, and is potentiallycapable of spreading the organism to otherscolonization: presence of microorganisms at a body site notassociated with active infectioncontact precautions: isolation practices for using personalprotective attire and other environmental procedures, designedto prevent transmission of serious illnesses or epidemiological-ly important infections/colonization that are easily transmittedby contact with the patient or with items in the patient’s envi-ronmentcontamination: the presence of microorganisms on inanimateobjectsdecolonization: removal of organisms at a body site(s), throughuse of topical and/or other treatment with antimicrobial agentsdisinfection: a process that eliminates many or all microor-ganisms except sporesendemic: the usual or expected occurrence of disease in apopulationepidemic: an excess over the expected incidence of diseasewithin a geographic area during a specified time period; dis-ease attacks many people at the same time

exposure: contact with an infectious agent or a non-isolatedinfectious personguideline: an instructional guide or reference to indicate acourse of action in a specified situationincidence: number of new cases of disease in a populationover a time periodinfection: condition in a host resulting from the presence ofand invasion by microorganismsnosocomial: infection that was not present or incubating at thetime of admissionobservation days: a coding classification for admissions,usually defined as less than a 24-hour stay on an inpatientunitoutbreak: the sudden increase in the incidence of a disease orcondition in a specific areaprevalence: number of cases of disease in a population at acertain point in timerate: number of cases in a time period divided by the popula-tion at riskscreening: examination of a population to detect the exis-tence of a particular disease or potential for developing adisease

GLOSSARY

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