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mortality (M&M) conferences and so forth—can be brought to bear to identify trends and sources of infectious disease.

Despite major efforts to decrease transmission, infection control remains a challenge to health care facilities. Indeed, in some ways it is more difficult now than in the past. Like other advances in patient care, the advent of antibiotics has dramatically improved patient care, but the emergence of antibiotic resistance means that new efforts of surveillance and prevention must be implemented in order to make progress against infection, and continuing efforts are needed to maintain earlier achievements.

According to the Centers for Disease Control (CDC), nosocomial infections affect approximately 2 million patients annually in acute care facilities in the United States at an estimated direct patient care cost of approximately $3.5 billion per year (NCID/CDC&P). In long-term care facilities including nursing homes, CDC estimates that more than 1.5 million cases of nosocomial infection occur each year, an average of one infection per patient per year.2 Epidemiological studies have estimated that one-third of nosocomial infections can be prevented by well-organized infection control programs, yet only six to nine percent are actually prevented.

Recognition of the danger of transmission of infection in the health care setting is credited to the insight of a Viennese obstetrician Ignaz Phillip Semmelweis in 1847. Semmelweis correctly identified the cause of an epidemic of childbed fever (puerperal sepsis) among maternity patients as originating from physicians who had previously done autopsies and then transferred bacteria (later found to be Streptococcus pyogenes) on their hands when they examined their patients. After Semmelweis introduced the practice of hand washing with a solution of chloride of lime (an antiseptic) before examination, maternal mortality decreased from 18 percent to 2.4 percent in the first month.3,4 According to CDC, even today, ''handwashing is the single most important means of preventing the spread of infection." Yet, repeated studies indicate that after more than 150 years of experience, lack of or improper handwashing still contributes significantly to disease transmission in health care settings5,6,7,8,9,10,11 Exhortations to personnel have not been effective, and some organizations have begun to look at system barriers to handwashing (e.g., the time required as well as the chapping and irritation caused by frequent handwashing) and ways to eliminate these problems by designing better hand hygiene processes.