Hospital Infection Control Committee Research Articles

Evaluation of Antibiotic Prophylaxis in the University of Gaziantep Medical Faculty Research Hospital Surgical Departments

The aim of this study is to evaluate the use of prophylactic antibiotics in surgery clinic of our hospital. A total of 101 patients underwent operation at the surgical clinics of Gaziantep University Medical Faculty Hospital on December 10, 2009 included to the study. A structured data form containing information about patients and used antibiotics completed by the nurse of hospital's infection control committee and her assistant. Patient selection was based on the classification of injury. All patient information forms were evaluated by infectious disease specialists using the surgical prophylaxis guide. A total of 128 antibiotics have been used for 101 patients, participated in the study. Prophylactic antibiotic selection were appropriate in 57.4% of all selected antibiotics (n = 58). The spectrums of 37.5% of single and dual used antibiotics were not appropriate. Besides, 35.2% of penetration and 73.2% of duration of use were not appropriate. In our study, most of the errors in surgical prophylaxis were seen in the duration of use. Besides, the unnecessary application and use of broad-spectrum antibiotics are seen. The wrong practices in surgical prophylaxis lead to unnecessary antibiotics treatment to the patients, development of resistance and also burden to the budget of the country.

Analysis of the molecular epidemiology and antibiotic sensitivity of vancomycin-resistant enterococci

Vancomycin-resistant Enterococci (VRE) are important nosocomial infection agents which have become widespread in recent years. The legal obligation to establish hospital infection control committees and increase in monitoring studies in Turkey has generalized VRE notifications. The treatment options for VRE-induced infections are limited. This study was conducted to identify the molecular epidemiology of the VRE sources found in the study hospital, and to determine the resistance of these strains to various antibiotics. The study was carried out on strains isolated in the microbiology laboratory of Sahinbey Research and Application Hospital, University of Gaziantep. Strains were identified at species level via conventional methods and a fully automated Vitek 2 (Biomerieux, France) identification system. Vancomycin sensitivity was tested via disc diffusion method and E-test (AB Biodisc) strips. Resistance genes of these strains were analyzed via PCR method using GeneOhm VanR (Becton Dickinson, Canada) moleculer tests. In vitro antibacterial efficiency of linezolid, dalfopristin, gentamicin, streptomycin and imipenem was analyzed via the disc diffusion method. All 81 strains included in the study were identified as Enterococcus faecium. VanA gene-type resistance was recorded in 76 (93.8%); vanB gene-type resistance in 2 (2.5%); and nonA-nonB type resistance in 3 (3.7%) of the study strains. No resistance was detected in any of the linezolid and dalfopristine strains. 75 VRE strains (92.6%) were found to be resistant to gentamicin, 28 strains (34.6%) to streptomycin and 79 strains (97.5%) to imipenem. Linezolid and dalfopristin were found to have complete in vitro efficiency against VRE strains, while these strains were found to be highly resistant to other antibiotics tested in the scope of the study. Since treatment of VRE-induced infections is relatively difficult, it is suggested that careful implementation of preventive measures is of great importance to patients in the fight against this agent.

Immune status and risk perception of acquisition of vaccine preventable diseases among health care workers

Risk perception of acquiring vaccine preventable diseases and the immune status of 187 health care workers (HCW) from a high-complexity university hospital in São Paulo, Brazil, were assessed. The vaccine preventable diseases more cited as at risk for acquisition were hepatitis B (94.1%), influenza (92.5%), meningococcal disease (90.3%), tuberculosis (85.0%), and varicella (72.7%). Previous disease or vaccination reported by HCW were hepatitis B (82.4%), tetanus (87.7%), diphtheria (81.8%), measles (86.6%), mumps (85.6%), rubella (85.0%), varicella (82.9%), and influenza (35.8%). One third of HCW reported previous percutaneous or mucosal occupational accidents, and 83.6% had notified the event to the Hospital Infection Control Committee. Despite good risk perception of acquiring vaccine preventable diseases, only 35.8% of individuals were fully immunized. Efforts should be made to increase influenza vaccination coverage among all professionals and to reduce the number of nonreported accidents, especially among physicians.

Perception in Relation to a Potential Influenza Pandemic among Healthcare Workers in Japan: Implications for Preparedness

Due to the potential for an influenza pandemic, preparedness for infection control in healthcare settings is essential from the standpoint of occupational health for healthcare workers. We conducted questionnaire surveys among Japanese hospitals to assess preparedness at the individual and institutional levels and their inter-relationship. Questionnaires were administered at 7 tertiary hospitals in Japan during the spring of 2006. We analyzed 7,378 individual responses of the 10,746 questionnaires administered and all seven institutional responses by hospital infection control committees. Healthcare workers assigned low importance to personal protective equipment and showed mixed attitudes (anxious but accepting) to the potential risk. Institutional gaps existed in preparedness across hospitals and most hospitals lacked the specificity to cope with a pandemic. A higher level of institutional preparedness, as determined by expertise as well as general and specific countermeasures, was an important predictor of individual recognition of preventive measures, perception of institutional measures, and attitude toward coping with risk. A higher level of institutional preparedness stood out to be an important predictor of individual preparedness. Considering the risk of a future influenza pandemic, hospitals should improve preparedness at all levels.

A contact investigation of the transmission of Mycobacterium tuberculosis from a nurse working in a newborn nursery and maternity ward

A nurse working in a newborn nursery and maternity ward developed 3+ smear-positive lung tuberculosis. The hospital infection control committee, in collaboration with the local public health and welfare center, conducted a contact investigation. The infection period was defined as April to August 2006. The investigation included 109 infant and mother pairs, 28 children aged under 10 years and their guardians, 62 coworkers, and 63 household visitors to the ward. Tuberculosis infection in infants and children aged under 5 years was primarily determined by tuberculin skin test (TST), while subjects aged 5 years or more were tested using QuantiFERON-TB Gold (QFT). The first investigation, in August 2006, was conducted in all subjects, and the second investigation, in October 2006, targeted selected subjects. No infants were TST-positive. Two children aged 1 year or under, vaccinated with bacillus Calmette-Guérin, were positive for TST, as determined by the criteria of the Japan Anti-Tuberculosis Association; however, other tests for tuberculosis were negative. Of the 13 QFT-positive adult subjects, 1 mother and 2 coworkers could have become infected with Mycobacterium tuberculosis through exposure to the index nurse. Fifty-four infants and 6 children underwent "window-period" prophylaxis, and 4 adults completed 6-month prophylactic treatment with isoniazid. To date, no secondary cases of tuberculosis disease have occurred.

Enhancing Compliance With Medicare Guidelines for Surgical Infection Prevention

The Center for Medicare and Medicaid Services instituted standardized reporting of measures aimed at surgical infection prevention (SIP). The complexity and number of medical personnel involved in antibiotic administration requires multiple disciplines to successfully improve compliance. Survey study. Tertiary care university hospital. All patients undergoing the following operations from July 2004 through December 2005 were monitored for compliance with SIP: (1) coronary artery bypass graft, (2) other cardiac, (3) vascular, (4) hysterectomy, (5) colon resection, (6) hip arthroplasty, and (7) knee arthroplasty. A team including a surgeon, an anesthesiologist, nurses (preoperative, operating room, and floor), a pharmacist, a hospital infection control committee member, and quality improvement and operations specialists was created in July 2004. Hospital guidelines for SIP were defined, personnel roles defined and processes standardized, and communication/education for health care professionals was enhanced. Compliance with 3 SIP measures over 3 consecutive periods of 6 months each: (1) percentage of patients receiving antibiotics within 1 hour of incision, (2) percentage of patients with appropriately selected antibiotics, and (3) percentage of patients with antibiotics discontinued within 24 hours of operation end time. One thousand seventy-two patients were monitored. Measure 1 compliance improved from 72.25% to 83.78% (P<.001, Cochran-Armitage trend test); improvement or high performance (>90% compliance) was demonstrated in 5 of 7 services. Measure 2 compliance remained uniformly high (approximately 98%). Measure 3 compliance improved from 54.5% to 87.16% (P<.001); improvement was seen in 5 of 7 services. The clearly defined roles of a cross-disciplinary team and the process improvements discussed in this article can easily be implemented in other institutions. These elements were integral to our success in improving the timely delivery and discontinuation of prophylactic surgical antibiotics.

Loaner Instrumentation: Processing the Unknown

The use of loaner instrumentation is a growing phenomenon in today's expanding health care environment. Central processing department personnel at Walter Reed Medical Center, Washington, DC, undertook a project to determine if loaner instrumentation coming into the facility had been decontaminated. Sixteen percent of the loaner instruments tested were positive for blood residue. The results of this project were used to strengthen internal standard operating procedures and to alert the hospital's infection control committee of a potential safety problem.

The perception of the healthcare workers about the Hospital Infection Control Committee - an exploratory study

Introduction:The actions of the Infection Hospital Control Comitte (HICC) according to federal regulations 2616/98, are based essentially on the surveillance epidemiologic that makes possible the definition of guidelines’s prevention and control infection. However a high unrest for the health care workers refer the fact that during the health care they haven’t understood that the infection control is an ineherent aspect in their practice because of the risk in manipulation of organic matter, secretions and excretions, in addition to contact with microorganisms disseminated by differents route of transmission.Objective: to identify the perception of the healthcare workers team about the performance of Infection Hospital Control Committee (HICC). Methods: This is a descriptive study, completed in a hospital university of Belo Horizonte. A questionnaire was applied to 86 professionals (nurses, physicians and physiotherapists). Results: It was found that 88% of the professionals had knowledge of the meaning of the acronym HICC, 64% of them could identify a case of hospital infection, however just 48,8% had knowledge about the identification criterion of the resistant microorganisms. The lack of knowledge and commitment were the main cause for the low or not adhesion of control measures for hospital infection. In relation to the professional’s perception of the HICC, the majority considers it actively participative. Conclusion: this study has important contributions for the reflections of the practices of the healthcare workers team, as well as, for the HICCs think about yours strategic of the training and involvement with the hospital community.

Reprocessing disposable single-use devices: From skepticism to success

ISSUE: The economic pressure to cut healthcare costs is driving facilities to consider reprocessing open but unused medical devices as well as used devices that are expensive. The reuse of disposable medical devices that are labeled “for single-use only” (i.e., single-use devices, or SUDs) raises legal, financial, ethical, and patient safety issues. PROJECT: A SUD reprocessing committee was formed at a university medical center with representation from the following departments: infection control, risk management, accreditation and patient safety, financial management, administration, sterile processing, materials management, procurement services, peri-operative services, radiology, and cardiology. The mission of the SUD reprocessing committee is to establish policies and procedures for the reprocessing of SUDs that will ensure patient safety and quality healthcare. RESULTS: The SUD reprocessing committee established the following policies: 1) Onsite reprocessing is strictly prohibited. 2) Reprocessing may be performed only by FDA-registered third-party reprocessing companies approved by the health system. 3) Each department will determine which SUDs are candidates for reprocessing. 4) Third-party reprocessing must be approved by the SUD reprocessing committee and the hospital infection control committee (HICC). 5) Departmental approval must be obtained for each SUD from the medical director or designated clinical leader based on their expertise in the use of the product. 6) The request to reprocess a SUD must be submitted to the SUD reprocessing committee for approval. 7) The SUD reprocessing committee will submit approved requests to the HICC for final approval. We began reprocessing Category I devices (BP cuffs, SCDs, pulse oximeter sensors, disposable stethoscopes) on June 1, 2003. We began reprocessing Category II devices (bits, burrs, blades, external fixation devices) on April 1, 2004. Beginning in July 2004, fiscal year-to-date savings for both Category I and II devices were $272,565. No patient safety issues related to reprocessing have been identified. LESSONS LEARNED: Successful implementation of reprocessing of SUDs is dependent upon careful analysis of potential risks and benefits. Our SUD reprocessing committee established policies to ensure detailed evaluation prior to approval of reprocessing selected items. SUD reprocessing resulted in substantial cost savings to our health system without compromising the care of patients.

Medical Bacteriology: a Practical Approach

Medical Bacteriology is a multicontributor work with chapters provided by various expert medical microbiologists from the United Kingdom. The information is organized into 4 basic areas totaling 12 chapters: 6 chapters covering the analysis of various types of patient specimens; 2 chapters on antimicrobial analysis, susceptibility testing, and direct assay in patient specimens; 2 chapters on laboratory management issues, including information technology, quality control, and quality assurance; and 2 chapters on the role of the laboratory in hospital infection control programs and in the support of epidemiologic investigations. Distributed throughout the text are 81 individual testing protocols, which can be found either by referring to a table at the front of the book or by searching the index. Also included are 4 appendixes. Multiple options exist for presenting the fundamentals of medical bacteriology. Some texts have used a disease-based approach. Other have used an organism-based approach. Medical Bacteriology takes a specimen-based approach: bacterial diseases and their causative agents are addressed through the proper collection, processing, and analysis of clinical specimens. From a laboratory perspective, the specimen-based approach has substantial advantages. In this text, the critical importance of proper collection and transport of specimens is clearly communicated for each specimen type, and appropriate protocols are provided. In addition, an in-depth discussion is presented on the proper interpretation of cultures and other laboratory findings for each specimen type. For example, the chapter on urine bacteriology contains not only guidelines for interpreting various types of urine cultures, but also the relevance of other routine urinalysis findings to infections of the urinary tract. One disadvantage of the specimen-based approach is that organism identification protocols may appear in multiple chapters. The chapters devoted to antimicrobial issues provide basic testing protocols and valuable insights on the selection of appropriate agents for routine testing and reporting. The relative advantages and disadvantages of diffusion versus dilution methods are clearly described, and readers from the United States may find some of the alternatives to the standard Kirby-Bauer procedure to be of interest. The chapters devoted to laboratory management provide excellent insights on the rapidly evolving field of laboratory information technology. Laboratorians should find the comparison of stand-alone legacy systems with more integrated hospital-wide and health system–wide designs useful in making decisions on laboratory information management. The chapters on infection control and epidemiology provide overview of the technical and administrative issues encountered by the laboratory. The organization and function of hospital infection control committees are discussed, and guidance for performing basic cohort and case-control studies is presented. Emphasis is placed on the processing and analysis of specimens with well-established protocols and materials. Bacterial identification and characterization protocols are based on techniques that have been in general use for many years. Readers interested in newer approaches and in analyses of some of the more exotic bacterial zoonoses are provided with appropriate references. The book flows smoothly from chapter to chapter. Similar material appearing in various chapters is appropriately cross-referenced. The text is clearly written, with jargon and acronyms kept to a minimum. At 409 pages, including the appendixes and index, this book can be easily read in a few sittings, and readers, including students, technologists, laboratory supervisors, and senior scientists, should find it to be a useful reference.

輸血後感染症検査実施率向上の為の取り組み

On July 30, 2003 the Revised Pharmaceutical Affairs Law and the Revised Transfusion Act were enacted by the Ministry of Health, Labor and Welfare to clarify the responsibilities of medical organizations. Taking this opportunity, the Hospital's Blood Transfusion Therapy Committee and Infection Control Committee undertook a review of methods of screening tests for post-transfusion infection. We decided to give patients a form letter to recommend they take a screening test for post-transfusion infection while providing notice to doctors that ‘2 months have passed since the transfusion (Blue Card)’. In addition, detailed discussions were held with respect to 1) test fees, 2) test criteria, 3) how to raise patients' awareness, and 4) how to enhance doctors' awareness. As a result, the use of screening tests for post-transfusion infection increased, from 6.8% to 54.6%, enabling us to confirm some effects. However, to fulfil our responsibilities to all patients receiving blood transfusion, the system for implementing this program requires urgent improvement. We thus aimed to further improve the system through operating the newly revised Blue Card system. In addition, it is necessary to create a system to ensure thorough implementation of the program with the electronic patient record due to commence in 2006.Meanwhile, the Ministry of Health, Labor and Welfare is expected to extend the application of patient assistance programs, in addition to implementing a system to ensure that patients receive safer blood transfusion.

Control of Methicillin-Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit by Modification of 2003 Society for Healthcare Epidemiology of America Guideline for Preventing Transmission of Resistant Pathogens

BACKGROUND: Invasive methicillin-resistant Staphylococcus aureus (MRSA) infection as a cause of death in hospitalized infants is rare and has not previously occurred in Arkansas Children's Hospital (ACH) neonatal intensive care unit (NICU). In August 2003, however two infants developed MRSA pneumonia and subsequently died. Anterior nares cultures during this outbreak found two additional infants colonized. In the first 7 months of 2003, the rate of MRSA among Staphylococcus aureus in ACH NICU was 75% (21/28). As part of control measures, we reviewed and modified the Society for Healthcare Epidemiology of America (SHEA) guideline for resistant pathogens published in 2003 for implementation. METHODS: After review of the guideline by the Hospital Infection Control Committee, the following interventions were selected: 1) cohorts of colonized/infected infants were established, 2) alcohol gel hand disinfectant was introduced, 3) admission surveillance cultures of the anterior nares were performed, 4) point prevalence surveys were conducted, and 5) an antibiotic susceptibility pattern, DNA sequence analysis of the staphylococcal protein A gene (SPA), and pulsed-field gel electrophoresis (PFGE) were reviewed to determine the similarity of MRSA isolates. RESULTS: Antibiotic Susceptibility pattern, SPA, and PFGE revealed that one pattern was responsible for this cluster of invasive disease in the initial group of infants. A point prevalence survey conducted in September of current high-risk NICU patients found four infants (hospitalized 25–197 days) colonized with MRSA; none matched the outbreak isolate. Because of the concern of unrecognized MRSA from other hospitals, admission cultures were collected between October and December. Three newly admitted infants were colonized with MRSA – two 25-week-premature newborns (day of life 58 and 10) and one 38-week-premature newborn (day of life 1) from separate facilities. Another point prevalence survey in December found two infants colonized (admission culture negative); none matched the outbreak isolate. The rate of MRSA among Staphylococcus aureus had declined to 45% (18/40) by January 2004. CONCLUSION: Even though it is labor-intensive and costly to implement (microbiology laboratory charges totaled $19,903.02), this SHEA guideline was a crucial component for control of MRSA in our NICU.

The monkeypox virus outbreak: Reflections from the frontlines

The day began as a rather typical Friday morning on May 30, 2003. The infection control practitioners were reviewing their telephone messages and preparing for the weekly staff meeting with both the hospital epidemiologist and the Chairman of the Froedtert Hospital Infection Control Committee, who was engaged in a discussion with one of our staff emergency department (ED) physicians about a veterinarian who was seeking treatment in the ED for a skin lesion and swollen lymph nodes. The veterinarian had a history of recent exposure to an ill pet prairie dog. At the time, little did we know that a series of events would set into motion a full scale epidemiologic investigation encompassing our own hospital in addition to local, state, and federal health agencies, entirely because of a smallpox-like virus that had never been seen before in the Western hemisphere.1

Factors influencing hospital infection control policies in Italian hospitals

A study was undertaken to determine the resources available in Italian hospitals for the control of nosocomial infections and the factors favouring a successful approach. During January–May 2000 a questionnaire about infection control was sent to the hospital health director of all Italian National Health System hospitals treating acute patients and with more than 3500 admissions in 1999. An active programme was defined as a hospital infection control committee (HICC) meeting at least four times in 1999, the presence of a doctor with infection control responsibilities, a nurse employed in infection control and at least one surveillance activity and one infection control guideline issued or updated in the past two years. There was a response rate of 87.5% (463/529). Almost fifteen percent (69/463) of hospitals had an active programme for Infection Control and 76.2% (353/463) had a HICC. Seventy-one percent (330/463) of the hospitals had a hospital infection control physician and 53% (250/463) had infection control nurses. Fifty-two percent (242/463) reported at least one surveillance activity and 70.8% (328/463) had issued or updated at least one guidance document in the last two years. The presence of regional policies [odds ratio (OR) 8.7], operative groups (OR 4.2), at least one full-time nurse (OR 4.6) and a hospital annual plan which specified infection control (OR 2.1) were statistically associated with an active programme in the multivariate analysis.

Frequency of occupational accidents caused by sharp-edged hollow-pointed equipment and biological fluids among medical students and health personnel in a teaching hospital in the city of Brazilia

The objective of the study was to check and analyze the occurrence of work accidents caused by sharp-edged hollow-pointed equipment and biological fluids among medical students and health personnel. It was carried out in a Brasilia university hospital. The data were collected from records of work accidents kept by the Hospital Infection Control Committee, from August 1998 to June 2000. It has turned out that 117 persons were victims of work accidents, the vast majority of them caused by needles. The study has reached the conclusion that the accident prevention system must be improved at the above mentioned hospital.

The organization of hospital infection control committees and their importance in Brazil.

The importance of Hospital Infection Control Committees (HICC) increases every year due to the emergence of multiresistant bacterial strains, hospital outbreaks, and other factors that cause HI. This demonstrates the fragility of the quality of hospital and medical care. Having a well-organized HICC benefits hospitals by improving quality, lowering costs and, most important, reducing patient morbidity and mortality. This review records the history of the development of HICCs, their present organizational structure, and offers recommendations for hte best methods of infection surveillance.

Protecting Vulnerable Groups in the Home: The Interface between Institutions and the Domestic Setting

1. Classifying of diseases into protection levels 1–4 according to degree of immunosuppression 2. Allocation of preventive measures to protection levels 1–4 3. Categorization of the recommendations Edited transcript of an oral transcript Immunocompromised patients have a higher risk of infection. Since the consequences for patients who are in an immunosuppressed state can be life-threatening, we as practitioners or nurses should be concerned. We know that there are both endogenous and exogenous infection risks for these people and our aim as hygienists is to develop prevention strategies for a health-promoting and health-protecting hospital and home environment. This can be done not only by prescribing therapies, but also by improving the design of the wards, or rooms in the domestic home, and by having water quality, air quality, and cleaning and disinfection strategies.1 All of these items as part of the prevention strategy can protect our patients whether they are in the hospital or home. Nearly 85% of organisms responsible for infections in patients with, for example, cancers, are derived from the indigenous flora,2 but nearly half of these micro-organisms are acquired from the hospital or the home environment. Events are not static, but rather exert their impact dynamically.3 When the neutrophil count drops there is an increasing risk of pneumonias, bacteraemias, catheter-related urinary and bloodstream infections, and fevers of unknown origin. In liver transplant patients, for example, the risk depends on the time after transplantation. There is a high risk of severe bacterial, fungal and viral infections in the first 2 months, and a risk of protozoal infections for up to 6 months after transplantation. In Germany, the Hospital Hygiene and Infection Control Committee at the Robert Koch Institute has the task to develop national guidelines that are both evidenceand consensus-based. I want to talk about the development of one of these guidelines ‘Hygienic measures in

Parallel automated knowledge acquisition of case-based semantic networks from relational databases

The number of databases that are accessible over networks within organizations is increasing. This paper presents a methodology for automatically converting the data in these databases into a useful knowledge base of case-based semantic networks that can be accessed through a browsing facility. A parallel processing strategy has been implemented for this knowledge acquisition process to support its scalability to large databases. This methodology has potential application in the development of organizational intranets. It can also be used for retrospective browsing of the context of interesting patterns discovered by data mining. The database examples used in this paper are from clinical laboratories that provide data to a hospital infection control committee. Even though the results presented here use a single domain, the methodology can be used with no changes to explore the construction of multidomain knowledge bases.

Improving clinical outcome in bacteremia.

Bacteremia is associated with significant morbidity and mortality. There is wide variation in morbidity and mortality rates according to organism and predisposing conditions. Additionally, prompt administration of appropriate antimicrobial agents is associated with a decrease in mortality. Unfortunately, many bacteremic patients receive inappropriate or no antibiotics. Infectious disease consultation can decrease the number of patients receiving inappropriate initial therapy. 'Quality standard for the treatment of bacteremia' (Gross et al., 1994, Infection Control and Hospital Epidemiology 15, 189-192) is a consensus paper; its purpose is to 'improve the treatment of hospitalized patients with documented bacteremia by ensuring that they receive an antibiotic appropriate in light of the blood-culture susceptibility of the pathogen isolated.' A programme to assess the treatment of bacteremia can improve the quality of care with a modest commitment of additional resources. Many of the activities could be performed by a pharmacist, infection control practitioner, or pathologist. However, physician-to-physician communications are most likely to be successful. This programme should be considered a component of a hospital's quality-improvement programme; either the hospital quality assurance or infection control committee could be responsible for the programme. We encourage adoption of the standard, and recommend prospective monitoring to include the choice of empiric antimicrobial agents.

PREPARO DO GRADUANDO DE ENFERMAGEM PARA ATUAR NA COMISSÃO DE CONTROLE DE INFECÇÃO HOSPITALAR (CCIH)

Este trabalho teve por finalidade realizar estudo sobre como as escolas de enfermagem do país estão preparando o graduando de enfermagem para atuar na comissão de controle de infecção hospitalar (CCIH); observamos que este ensino não vem sendo desenvolvido de maneira sistemática e planejada. A partir dos resultados obtidos, apresentamos uma proposta de ensino formal sobre a atuação da enfermeira na CCIH.