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Perspective on Nosocomial Infection Control
Gregory D. Luther, VP—Product Development

September 19, 2005

BioWarn, LLC, has discovered a breakthrough method for the detection of dangerous pathogens and is working on a final
proof-of-concept to be completed during the summer of 2005. This revolutionary, patent-pending technology—called
SmartSand™—integrates proven bio-science and micro-electronics in a new way that provides immediate alerts to the
presence of toxins, bacteria, or viruses and relays their identity to a local area network—all from a unit the size of a grain
of sand. The potential applications for SmartSand™ are numerous and are of interest to any enterprise, industry, or
public authority involved in assuring the safety and health of large numbers of people and the air, food, water,
mail/packages, environmental surfaces, and/or equipment they come into contact with in the normal course of work or
play. Initial target markets for SmartSand™ are healthcare, food processing, and bio-defense. Potential products
• Hand-held units for use by nursing staff, inspectors, infectious disease specialists,
• Point-of-care bedside diagnostics in hospitals and clinics,
• HVAC inserts to monitor buildings for outbreaks such as Legionnaire’s Disease or bio-terror agents,
• Surgical dressings, monitoring for bacterial infection,
• Surgical gloves, monitoring for presence of contagion during procedures or routine patient care,
• Contagion monitors embedded in food processing plants—ahead of where the public is placed at risk,
• Inserts in the walls of shipping containers to monitor for terrorist threats,
• Inserts in dental prosthetics or surgical implants (e.g. hip replacements) for long-term infection monitoring,
• Face masks or breathalyzers to screen international travelers for contagious diseases.

In this paper we focus on just one area, but one of critical importance: reducing or eliminating nosocomial infections in
healthcare facilities. If nosocomial infection were tracked by the Center for Disease Control, it would rank number six on
the list of leading causes of death in the U.S. in 2002—ahead of diabetes, influenza, pneumonia, and Alzheimer's. The
always-on pathogen surveillance capability of SmartSand™ represents a quantum leap for the field of infection
control and could transform the state of patient safety in our hospitals.

73,000 deaths, and close behind accidents at 107,000
I. Background deathsi.
It's estimated that in the United States alone there are • From 1975 to 1995 the rate of nosocomial
about 2 million nosocomial (i.e. hospital-acquired) infections per 1,000 patient days increased 36% -
infections each year, of which about 90,000 result in a from 7.2 to 9.8.
patient's death. That places nosocomial infection at
number five in the list of the top ten leading causes of • It is estimated that in 1995 nosocomial infections
death in the U.S. in 2002, ahead of diabetes at about cost $4.5 billion and contributed to one death
every 6 minutes.ii The current incidence of

p. 1
Copyright © 2005 BioWarn, LLC

directly Urinary tract infection No studies available 1. which are used when an infectious agent is present • Morbidity and Mortality Report found that that can be spread by skin-to-skin contact or by nosocomial infections cost $5 billion annually in contact with contaminated surfaces. VRE.24% of nosocomial S. In (ALOS) by between 7. thinks it will deal with (an infection) when they get an p. Centers for Disease Control and Prevention (CDC).703 41.Pneumonia 17.646 29.971 1. aureus pneumonias incurred .622 14.based on 55 published between studies from 1990-2000 (Source: AJIC) 1990-2000 Attributable Costs of Remediation calculated mean (US$ per bacteremia) mean + 1 std dev Intervention Costs (US$) mean mean + 1 std dev Times Return on Intervention $ mean mean + 1 std dev the average Nosocomial Infection (in general) 13. condition for the control of infection outbreaks. 2 Copyright © 2005 BioWarn. asymptomatic patients As shown in Table 1.497 62. the costs of an infection are far more important than infected patients in the outbreak are very substantial and far out-weigh the evolution of an epidemic.176 7X 5X excess costs Note: MRSA accounted for 54% of all S. • It is estimated that nosocomial infections have Neither. hospitals ICU stays by 8 days.Costs of nosocomial infections and infection control interventions . but they are probably not sufficient in themselves.377 52. as recommended by the bacterial infections. LLC .677 38. which represents a $500 million increase in noted infectious disease expert Barry M.138 2.282 4. or some other infectious agent (i.689 Other No studies available 27. substitution. nosocomial mortality is most likely higher because An effective program to combat infections includes of the tremendous increase in antibiotic-resistant contact precautions. and cycling.688 7X 3X #2 . and . MD. or on the body but does not cause illness.962 n/a resultant by Pathogen MRSA 35.973 31.808 8.e.Bloodstream 38.466 27 n/a (i.iv infection control program.132 was cost-saving n/a infection #3 . Active culture A key driver of this problem is the rise of multi-drug surveillance involves the detection and tracking of all resistance and the continued ascendancy of patients who are asymptomatically colonized with "superbugs" such as methicillin-resistant Staphylococcus MRSA.5 Health System. increased order for these measures to be effective. aureus surgical site infections versus a Tuberculosis No studies available 61. A has been caused). have doubled in a infection means the organism is present and disease decade and represent half of all S. aureus infections.Surgical site 15. He says.4 to 9. The annual cost of nosocomial hospital epidemiologist for the University of Virginia infections might now be on the order of $5.338 control Measles No studies available 41.367 38. increased morbidity by 35%. aureus (MRSA).065 patients) and compared them to the costs of infection controlv: Farr explains that colonized.49% of nosocomial S.e. for example.087 n/a group of Varicella zoster virus No studies available 27.4 days. four years. aureus infections in ICUs in 1999. According to 1999iii. vancomycin-resistant enterococci (VRE) "colonization" means the microorganism is present in and penicillin-resistant Streptococcus pneumoniae (PRSP).000.40% of nosocomial S.580 12X 12X attributable by Body Site costs of #1 . contact precautions are a necessary billion.825 5. whereas MRSA infection rates. "The hospital costs of infection control.446 148. should adopt active culture surveillance measures and increased total cost per patient for those together with contact precautions in a concerted patients who survived by approximately $40. are measures based on increased the system-wide average length of stay antibiotic restriction. Farr. aureus bloodstream infections . systematic literature review covering 55 studies published Table 1 . for that matter.

data indicating that contact precautions used on their own have little or no impact on controlling 1. clinical microbiology represent the tip of the iceberg. What Is SmartSand? infection. And that is the promise of BioWarn's with that approach… Patients who are recognized by SmartSand technology. critically important to the control of spread—together with effective barrier precautions—and such a concerted approach has been shown to reduce the spread of Bio- MRSA by 16-fold compared with standard Sensor precautions.outbreak. BioWarn and SmartSand™ probability sample of hospitals throughout the BioWarn's mission is to bring country. It showed that the intensity of surveillance full-time. The largest and most important was the Study of the Efficacy of Nosocomial Infection Control (SENIC) a study done by the Centers for Disease Control and Prevention in the 1970s and the 1980s on a II. monthly rather than weekly). or no use at all. But in spite of research safeguard patient safety. Surveillance cultures to identify this reservoir are. most health-care facilities have not yet tried SmartSand™ is a patent-pending bio-chip technology the concerted approach. then.vii healthcare facility by embedding its SmartSand™ technology in The Problem and the Opportunity familiar healthcare systems and As was illustrated in Table 1 above. LLC . Instead.) undertaken to detect the reservoir for spread. therefore. many hospitals are that can detect dangerous substances in real time— opting for low-frequency use of culture surveillance and at a fraction of the cost of alternative (e. BioPore Many studies confirm that contact precautions work when sufficient active-surveillance cultures are (Note: Depicts SmartSand detector at grain-of-sand scale. who represent most of the signal reservoir for transmission. always-on pathogen was the most powerful predictive factor with surveillance and protection respect to the control of infections to a lower within the reach of every level. p. (But) the barrier to adoption or usage—of active culture majority of colonized patients will not be identified surveillance. 3 Copyright © 2005 BioWarn."vi Active surveillance gets past the tip and detects the much larger. Most of an infection's spread comes from these clinically inapparent. invisible portion of the "iceberg"—those patients and healthcare workers who Bacteria or Virus are asymptomatically colonized. A technologies or techniques. Ligand Electrochemical colonized patients. Its characteristics include: high impact improvement opportunity in any healthcare facility's infection control process.g. hospital devices and by providing new administrators recognize that nosocomial infections categories of highly affordable create longer hospital stays and generate costs three detection products that times greater than normal. is to reduce the cost—and so reduce the and put (infected) patients in isolation. get the results from clinical microbiology.

As illustrated in Chart 1. “labels”. identifying the separation of the bio-chip from its reaction- “target. • Only communication devices are required as When fully developed. anywhere that the presence or spread of disease is RF. real-time pathogen surveillance systems • The unit uses background energy (cell phones.• Each detecting unit can be as small as a grain of • By detecting. digitizing. process performance generally wherever failure points can be found. SmartSand™ will deploy all of external equipment. • False-alarms are sorted and discarded before alerts are transmitted. a major concern. and secondary effects primary goal to be considered is that of increasing the (e. digitization. competing technologies. like chemiluminescence). etc. one device. 4 Copyright © 2005 BioWarn. i. and enhancing infection control reaction within the detector. SmartSand™ performs usage-intensity of active culture surveillance in direct measurement of a target pathogen’s chemical healthcare facilities. or viruses) to appear and interact. SmartSand™ removes the typical • The signature is processed.” ¾ They “wait” for “targets” (toxins. the substances using tags. SmartSand™ • The wireless alert transmission is facilitated via enables the deployment of automated. and voltage pattern-matching into • Electrodes acquire the “target’s” signature. bacteria. SmartSand™ enables a precision and • Each unit has a bioscience component and a sensitivity of detection not possible with microelectronics component. LLC . and storing the unique sand. • The bioscience component contains complex organic molecules (ligands). it's 1000 • By integrating target protein detection.g. on-line. • By combining pathogen detectors with wireless network communications features. The microelectronics component within a SmartSand unit is comparable to chips in disposable cameras. discreetly “waiting. a common p. other circuitry in the unit. ¾ Interactions release a very small electrochemical signature unique to the “target. • More mature than nano-technology. 2. voltage patterns produced by each target pathogen. SmartSand™ Benefits III. these capabilities in a unit no larger than a grain of sand. Product Design Goals Unlike other sensor technologies that detect As implied by BioWarn's mission statement.” ¾ Multiple “target” types can be detected by a single detector.) as a power source.e. times larger.” detection hardware and eliminates laboratory process steps requiring human intervention.

there is no reason that any healthcare worker —or patient—should be without a SmartSand™ The targeted outcomes listed in Table 1." and so the coverage of a SmartSand devices could facility's infection reservoir could be take the following forms: − SmartSand™ Chart 1 — The Chain of Infection and Points of Control Failure "breathalyzer" for screening of Hospital respiratory illnesses at Infection Counter. Because a SmartSand™ unit is an integrated circuit chip.1 provide a device. i. which is discussed in Section V below. For example. LLC . around $150 per verifiable. Points of BioWarn Improvement hospital admissions. SmartSand™ devices would increase the infection chain. or 2. The efficacy of infection control characteristic of such chips. it may be possible to provide a environmental surface sanitation—would for SmartSand™ detection product at no more than the the first time be made measurable and cost of a standard stethoscope. Use SmartSand™ devices to identify not colonized patients colonized patients SmartSand™ The Infection Reservoir Gloves sampling probes for Visitors Personal Protective Mask Inconvenient for staff and no ready way to Use SmartSand™ devices to flag PPE Equipment Gown verify efficacy use with laptop Infected Individuals Health- failures computers in wards or care Workers Hand Staff fall back to old habits and no ready Use SmartSand™ devices to verify Colonized Individuals Hygiene in the field. but generally not used due to expense. Vectors measures Failure Opportunities − USB-enabled Patients Patient Isolation Usually only applied to infected patients. at that price and reduction of infection control errors. for multiple pathogens. it can be mass-produced at the low cost per unit 3. and masks. and so a key barrier to the adoption of active culture surveillance would be removed.e. The cost of sampling and infection detection − SmartSand™-enabled general purpose wipes. 5 Copyright © 2005 BioWarn.source of failure across the infection control process By deploying such SmartSand™-based devices a is the absence of a feasible control step that assures healthcare facility would be achieving three key the quality of the infection counter-measures. would be dramatically reduced. cost and increase usage of active surveillance. Community way to verify efficacy compliance Environ- − Secure Digital. gowns. And as is the case for stethoscopes. p.or The Infection Reservoir mental Sanitation/ Sterilization No ready way to verify surfaces are Use SmartSand™ devices to flag Surfaces clean surface contamination Bluetooth-enabled Infected Individuals SmartSand™ Colonized Individuals Equipment Active Other measures ineffective without Use SmartSand™ devices to reduce Surveillance & Devices sampling probes for of Cultures this. − SmartSand™ -enabled surgical/examination increased substantially. "always-on. Depending on the countermeasures—like hand hygiene or specific features. But a objectives all at once: SmartSand™-based device can be designed and produced to fill this gap at multiple points in the 1. personal digital assistants (PDAs). and for effective frequency of culture sampling to multiple types of disease vectors. basis for comparing SmartSand™-based pathogen surveillance with a conventional laboratory-based approach. gloves. allowing the rapid identification unit.

and signal pattern-matching into one healthcare facility safety device. as described number of cultures per infant per week was three and recommended by the Centers for Disease Control and a half. critical equipment • Gown use Eighteen were positive and the remaining 3846 • Adequate cleaning and • Mask use were negative. an effective program to combat care unit was 24 infants per day.1 — SmartSand™ Advantages Targeted Outcomes • People — By combining pathogen detection with wireless • Increased patient safety (lower network communications. VAviii: The cost of conventional infection control The average daily census in the neonatal intensive As mentioned above. SmartSand enables the observed rates of infection) deployment of automated. Table 1. The estimated infection includes contact precautions. p. and storing • Reduced time-to-diagnosis and unique signal patterns produced by target pathogens. and Prevention (CDC). SmartSand™: • Reduction or elimination of ¾ Eliminates laboratory process steps requiring human laboratory-based process steps intervention. • Increased patient confidence in signal digitization. prescription SmartSand™ provides a precision of rapid-detection not possible with alternative approaches. Active surveillance cultures were • Glove use performed for 46 weeks. LLC . on-line pathogen surveillance • Reduced cost and drain on staff time systems that a) greatly reduce the cost of staff time and training. and b) substantially reduce the scope for error. 6 Copyright © 2005 BioWarn. • Process — By integrating target (pathogen) detection. Three hundred and twenty-five disinfection of shared personnel cultures were performed and two were equipment positive. Every infant had three cultures (nares. The estimated total • Strict hand hygiene • Dedicated use of non- number of infant surveillance cultures was 3864. • Increased patient safety (lower rates of infection spread) ¾ Increased specificity allows for more rapid identification of “drug of choice” remedies that would otherwise take hours or days to analyze The following is a description of active culture IV. digitizing. Approaches to Infection Control surveillance in a neonatal ICU at University of Virginia Health System in Charlottesville. ¾ Substantially reduces time-to-detection. and so • Reduced time-to-detection and to enhances the ability to isolate infection in a patient sequestration population and differentiate it in individuals • Technology — By detecting. They include: axilla and groin) and some infants had additional • Patient isolation • Appropriate patient cultures if a wound was present or the umbilicus transport had not healed.

25 active culture positive culture (wages) surveillance is Cost per culture $ 6.87 mostly attributable of which lab-related 85% 90% to laboratory staff Number of surveillance 3. and the surveillance.5 Cost per patient-week $ 69. for many Description Quantity/Work Labor/Materials Estimated Costs per Unit Negative Positive Culture hospitals the key Culture barrier to adoption Nurse sample collection time 3. always-on pathogen detection active culture surveillance.62 dollars per positive $ 4. a hospital wishing to spend less than $500. capability.0 minutes per 17. three of the SmartSand™ features are cost of a daily surveillance regimen would exceed $12 particularly valuable: its small size. for Total weekly cost for 100 patients surveilled weekly $6.000 per year could Given the high cost of lab-based active culture only afford a monthly surveillance regimen." Journal of Hospital Infection (2002) 51: 126-132) Table 2.Costs of Active Surveillance of Cultures culled from this (Source: "Cost-effectiveness of controlling MRSA. SmartSand-based.1. facility.800.0 minutes per 17.0 negative culture 2.0 per patient-sample time and Number of cultures per patient. the cost of negative culture (wages) 15.0 be surveilled.00 (wages) of active culture Disposable lab supplies 1.000 spend about $1.64 materials—85% to 90% in this case.13 500 bed facility.62 simply be the high culture cost. the week for weekly costs of a surveillance laboratory-based. As shown in Lab technician time 10.00 dollars per hour $ 1.0 minutes per sample 20.8 Estimated annual cost for 500 patients surveilled weekly $ 1. p.02 $ 103." Journal of Hospital Infection (2002) 51: 126-132) Estimated Costs of study. would Estimated annual cost for 100 patients surveilled weekly $ 360. Percent of cultures testing 0. and its low cost.83 Table 2.47% positive (based on UVA full-time.5 per patient-week Number of cultures per sampling 3.00 dollars per hour $ 4.74 surveillance may culture 1.00 dollars per hour $ 2.87 per positive culture $ 49. A negative 1045 cultures per week $ 6. Similarly. it can be deployed as a variety of hand-held or smaller devices. example) wide active culture Number of cultures testing positive (based on UVA surveillance example) 5 cultures per week $ 9.869.Based on data Table 2 .74 dollars per negative $ 2. when Description Quantity/Work Estimated Costs of Estimated Costs per Unit Negative Positive Culture multiplied by the Culture number of beds to Beds to be surveilled 100 Cultures processed per 1050. 10.35 program can run into the millions of Percent of cultures testing negative 99.00 $ 1.000 million per year in staff time and laboratory materials to support a weekly regimen of 1. 7 Copyright © 2005 BioWarn. its always-on million per year—a cost no hospital could afford.53% dollars per year for Number of cultures testing a large hospital. And as shown in Table 2.0 positive culture 4.Costs of Active Surveillance of Cultures (Source: "Cost-effectiveness of controlling MRSA. Because of SmartSand™'s small size. LLC .918 example.57 per negative culture $ 6.57 $ 9.1 .

respirators.7 = 1 in 4. and sterilization step worked as intended. device.000 of residual cost in this example. hygiene has been observed by everyone at a patient's bedside. benefit of the SmartSand™ technology to a healthcare facility is that it makes the infection control Because of its always-on capability.000 25. Table 2. or even hourly—but that represents a quantum leap for the field of minute-to-minute surveillance that a lab-based process infection control.2. that hand. In other words—short of sampling cost of the SmartSand™ devices. monthly surveillance would only have a 1-in-4 chance A comparison of infection control process outcomes of identifying a colonized but asymptomatic patient. into growing confidence in the for Annual Admissions of… 10. which account for over 85% of the total process cost. Of the estimated $260. and those and culturing every surface. the always- Always-on culture surveillance brings 100% coverage on pathogen surveillance capability provided by and minimizes the chance that an incoming patient SmartSand™ increases the chance of detecting a will contract an infection from a reservoir resident in patient colonized with a "super-bug" to100% for a the hospital. The impact of the "always-on" capability on patient safety is very significant because reducing the frequency of surveillance increases the chance that the reservoir of infection represented by colonized patients will go undetected—and uncontrolled—for longer. That means that further across the infection control process is the absence of opportunities for efficiency improvement lie more a control step that assures the quality of the infection with the methods of sample collection than with the counter-measure. Overall. Surveillance Chance of Identifying an = 1 in 0. That translates into greatly improved patient safety. SmartSand™ devices and consumables only As was stated earlier. measurable.Chances of Detecting Contagion and eventually. the common point of failure account for 18%. LLC . provides the equivalent of full-time culture manageable to a degree not otherwise possible.000 community that hospitals are safe places in their own Number of Hospital Beds 500 500 right.0 The major cost savings that SmartSand™ would bring Colonized Patient w/ Weekly Surveillance is in the reduction or elimination of the laboratory- based steps from the infection control process. or that visitors entering a hospital are not p. cannot deliver. and therefore. As shown in Table 2. and person and opportunities may be realizable through products that sending it to the lab throughout the day—there is no embed SmartSand™ detectors in surfaces and reasonable way to check that a sanitation or equipment—like hospital bed-rails.4 = 1 in 1. fraction of the cost of lab-based culture surveillance. SmartSand™ process verifiable.or it can be embedded in existing devices or carriers of MRSA or some other contagion. catheters—in order to provide continuous sampling. is summarized in Table 3 below. Of all the improvement opportunities that Patients/Bed per Year 20 50 SmartSand™ could be used to address in a healthcare Chance of Identifying a = 1 in 1.2 . And surveillance—not just daily.2 facility. in V. the biggest may be the chronic under-use of Colonized Patient w/ Monthly active culture surveillance in our hospitals.000 admissions per year. Analysis a 500 bed hospital with 25. 8 Copyright © 2005 BioWarn. A critical equipment.

but may not surveillance devices/products demonstrates innovation hospital safety be financially feasible and reinforces patient and community confidence. • Substantially reduces or eliminates both staff and drain on staff time particularly in the lab. prescription Increased patient • Culturing of samples • The potential for spreading a contagion over a two day safety (lower rates takes 1 to 2 days. and its high level diagnosis and takes 1 to 2 days. 9 Copyright © 2005 BioWarn. • May be able to reduce cost of sample collection by embedding SmartSand™ in existing equipment. detection takes 1 to 2 days. Technology Reduced time-to- • Culturing of samples • SmartSand™ detection is immediate. Reduced cost and • Increases staff costs. and by improving the performance level from weekly or monthly surveillance (or none) to always-on pathogen surveillance. period is eliminated for every colonized patient of infection spread) identified. materials costs in the lab.VI. • Culturing of samples • SmartSand™ detection is immediate. which account for ~90% of over all cost. to100% for a fraction of the cost of lab-based culture surveillance. LLC . By removing cost as the key barrier to the adoption of active culture surveillance. Process Increase patient • Would improve • Visible presence of SmartSand™ always-on pathogen confidence in confidence. of specificity can accelerate time-to-diagnosis. SmartSand™ has the potential to be the key innovation allowing our healthcare system to bring nosocomial infection under control and remove Table 3 — Outcome Comparison Conventional Lab- Targeted based Culture Outcomes Surveillance SmartSand™-based Surveillance People Increased patient • Can reduce the failure • Always-on SmartSand™ pathogen surveillance safety (lower costs of infection by a increases the chance of detecting a colonized patient infection rates) factor of 7 to 12 times. p. Conclusion nosocomial infection from the list of top-10 causes of death in America. Reduced time-to.

271 3. established 4. Cost-effectiveness of active surveillance number 301-926-9050. Kawar LN. Jointly. • Choosing pathogens to be detected February 25. We are looking for 1. Diabetes: 73. etc. www. Larson E. BioWarn. Special Issue. designs ( (Accessed July 18.Full-Length Doctor's Interview.974 10.05/2003: "Stricter vi Precautions. Chronic lower respiratory diseases: (Accessed July 8. A systematic inserts.681 regulatory approvals for them. “Press Ganey Knowledge warning thresholds Summary: The Cost of Nosocomial Infection. onboard.FASTATS .htm (Accessed partners to collaborate on the design and testing of August 21. ii technologies. 2000. Cancer: 557. Jeff Riggs. approach (wireless. 10 Copyright © 2005 BioWarn.249 7. 2002 Jun. No. Please contact Dr. Septicemia: 33. 3. p. July Sept 1998. HVAC system v Stone PW.) audit of economic evidence linking nosocomial infections and infection control interventions: • Integrating the network communications 1990-2000.” (2003). Alzheimer's disease: 58.51(2):126-32. 49. Farr viii these exciting market opportunities. nephrotic syndrome. LLC.816 relationships with key buyers in this field. Morbidity and Mortality Weekly Report (MMWR). etc. Am J Infect Control 2002.865 be rapidly integrated with existing marketing channels to tap the multi-billion dollar market opportunities for rapid pathogen detection Weinstein RA. Emerging Infectious Diseases. Simonton BM. Vol 4 No. • Developing SmartSand™ end-user product 2005). 2005). experience 5. Durbin LJ. Influenza/Pneumonia: 65. 138.) Infection Control Today . 7. 2005) BioWarn. Nosocomial Infection Update. Heart disease: 696. LLC. Press Ganey.672 markets for pathogen detection. Nephritis.cdc. we can 9. and a strong reputation 8. • Establishing background contaminant levels and iv1.866 for innovation and customer-focus.pressganey. President and COO. to discuss your needs and to explore Karchmer TB.ivanhoe. handheld devices. LLC . _________ p." http://search." • Estimating production costs to support business vii Ivanhoe's Medical Breakthroughs - and marketing strategy development "Unnecessary Illness: Four Steps to Save Patients' Lives -.742 with developing medical devices/products and gaining The list is as follows: SmartSand™-based products. Stroke: 162. J Hosp Infect. This prototype development process will include: Forth Decennial International Conference on iii Nosocomial and Healthcare-Associated Infections.g.) cultures and contact/droplet precautions for control of methicillin-resistant Staphylococcus aureus.947 partners who have a deep understanding of the 2. References: * * * * * iN C H S .30:145-52. Vol. LAN. and nephrosis: develop SmartSand™ product prototypes that can 40. Accidents (unintentional injuries): 106. (Telephone BM.Deaths/Mortality. is currently selecting corporate www.