1. Hospital Epidemiology
What is it and what is it good for?
Edward O’Rourke, M.D
Harvard University -
Harvard Medical School

2. "It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm"
Florence Nightingale

3. Nosocomial infection =
Nosocomial infection = Any infection that is not present or incubating at the time the patient is admitted to the hospital

4. History of infection control and hospital epidemiology
Pre 1800: Early efforts at wound prophylaxis
: Nightingale, Semmelweis, Lister, Pasteur
: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus
’s: Documenting need for infection control programs, surveillance begins
1980’s: focus on patient care practices, intensive care units, resistant organisms, HIV
1990’s: Hospital Epidemiology = Infection control, quality improvement and economics
2000’s: ??Healthcare system epidemiology
modified from McGowan, SHEA/CDC/AHA training course

5. Why do we need hospital epidemiology??
Hospitals are complex institutions where patients go to have their health problem diagnosed and treated
But, hospitals and medical/surgical interventions introduce risks that may harm a patient’s health

6. Consequences of Nosocomial Infections
Additional morbidity
Prolonged hospitalization
Long-term physical, developmental and neurological sequelae
Increased cost of hospitalization
Death

7. Challenges to the hospital epidemiologist
Make a hospital safe
Prevent harm to the patient and employees
initial focus on infectious diseases
increasingly all adverse (harmful) events are targets
Improve hospital efficiency
Eliminate unnecessary costs
Eliminate wasteful practices

8. What is hospital epidemiology?
The fundamental roles of hospital epidemiology are to:
Identify risks
Understand risks
Eliminate or minimize risks

9. What is the role of hospital epidemiology?
Identify risks to patient’s health
Find nosocomial infections
surveillance
Identify and study risk factors for nosocomial infection
understand epidemiologic principles and methods
case-control and cohort studies, bias, confounding
understand nosocomial pathogens
what is it about hospitalization that increases risk?

10. What is the role of hospital epidemiology?
Eliminate or minimize risks to a patient’s health
organize care to minimize risk
eliminate risk factors
work around risk factors
develop improved policies and procedures
educate physicians and nurses regarding risks
study risk factors to learn more about them and how to eliminate them

11. Responsibilities of the Infection Control Program
Surveillance of nosocomial infections
Outbreak investigation
Develop written policies for isolation of patients
Development of written policies to reduce risk from patient care practices
Cooperation with occupational health
Cooperation with quality improvement program
Education of hospital staff on infection control
Ongoing review of all aseptic, isolation and sanitation techniques
Monitoring of antibiotic utilization
Monitoring of antibiotic resistant organisms
Eliminate wasteful or unnecessary practices

12. Areas of interest to a hospital epidemiologist
Surveillance for nosocomial infection
bloodstream infections
pneumonia
urinary tract infections
surgical wound infections
Patterns of transmission of nosocomial infections
Outbreak investigation
Isolation precautions
Evaluation of exposures
Employee health
Disinfection and sterilization
Hospital engineering and environment
water supply
air filtration
Reviewing policies and procedures for patient care

13. Areas of interest to a hospital epidemiologist
Antibiotic use
Antibiotic resistant pathogens
Microbiology support
National regulations on infection control
Infection control committee
Quantitative methods in epidemiology

14. Organizational topics in hospital epidemiology
Relationship of Hospital to External Agencies and Organizations
Personnel
Who does the hospital epidemiologist report to?
Authority
Resources

15. Authority of Infection Control Program
Accreditation mandates: Must meet for accreditation (example in USA: JCAHO)
Infection Control Program
Infection Control Committee
Authority statement
OSHA mandates: Safety regulations
Infection Control Department reports to Hospital Administration, not Medicine/Surgery or Nursing
Enhanced authority through cooperation, mutual respect, and shared goal of improving patient outcome

16. QI versus Regulatory Strategies in Infection Control
Regulatory approach
External organizations establish rules and regulations
Data collection for comparison with outside standards
Inspections for compliance
Penalties for non-compliance
TQM/QI approach
Internal organization of hospital staff to develop goals and methods
Data collection for internal review
Continuous efforts to improve
Failure belongs to the entire system, not an individual

17. Organizing for Infection Control
Requires cooperation, understanding and support of hospital administration and medical/surgical/nursing leadership
There is no simple formula:
Every hospital is different
Every hospital’s problems are different
Every hospital’s personnel are different
The hospital must develop its own unique program

18. Changes in Nosocomial Infection Rates in Hospitals with or without Effective Programs
SENIC Study, CDC

19. Essential Components of an Effective Infection Control Program (after SENIC)
One full time infection control practitioner per 250 beds
optimal ratio may be different
A physician with training and expertise in infection control
Surveillance and feedback of rates to clinicians
Control activities (interventions, policies, training)

20. Personnel Hospital Epidemiologist Infection Control Practitioner
MD with clinical training
Usually part time salaried by the hospital for infection control duties and part time as infectious diseases clinician
Training in infection control
Infection Control Practitioner
Usually a nurse but can be a microbiologist
Has clinical experience before entering infection control
Full time in infection control, no other clinical or administrative duties

21. Organizing for Infection Control
Main elements
Develop an effective surveillance system
Establish policies and regulations to reduce risks
Develop with clinicians (physicians and nurses)
Develop and maintain a program of continuing education for hospital personnel
Use scientific (epidemiologic) method to study problems and test hypotheses

22. Organizing for Infection Control
Additional elements of an effective program
Antibiotic monitoring and control
Microbiologic laboratory liaison
Antibiotic susceptibility data dissemination
Occupational health
Provide resource to other departments for quality improvement study design and data analysis

23. Key elements of surveillance
Defining as precisely as possible the event to be surveyed (case definition)
Collecting the relevant data in a systematic, valid way
Consolidating the data into meaningful arrangements
Analyzing and interpreting the data
Using the information to bring about change
adapted from R. Haley

24. Infection Control Committee Purpose
Advisory
Review ideas from infection control team
Review surveillance data
Expert resource
Help understand hospital systems and policies
Decision making
Review and approve policies and surveillance plans
Policies binding throughout hospital
Education
Help disseminate information and influence others

25. Infection Control Committee
Committee Representatives
Hospital Epidemiologist
Infection Control Practitioners
Administrator
Ward, ICU and Operating room Nurses
Medicine/Surgery/Obstetrics/Pediatrics
Central Sterilization
Hospital Engineer
Microbiologist
Pharmacist

26. Infection Control Committee
Qualifications to be on the committee
Interest
Represent group in hospital
Experts in their field
Diplomatic
Good communicators

27. Resources: Where to get more information or help
Training Courses
Society of Hospital Epidemiologists of America (SHEA)
Association of Professionals in Infection Control (APIC)
National courses and congresses
Books
Textbooks: Bennett and Brachman - Wenzel - Mayhall
APIC Curriculum and Guidelines
CDC Guidelines
Journals
Infection Control and Hospital Epidemiology
Journal of Hospital Infections
American Journal of Infection Control
Consulting services
National: CDC, Ministry of Health
Colleagues

28. What is Hospital Epidemiology good for?
Infection control
Quality improvement
Controlling costs
An effective hospital epidemiology program can help achieve all three goals

29. Risk factors for surgical wound infection
Infection at another site
Prolonged procedure
Drains
Urgency of surgery
Foreign body
Skill of surgeon
Age
Obesity
Malnutrition (low albumin)
Diabetes
Steroids/immunosuppression
Prolonged pre-op hospitalization

30. Strategies to develop effective patient care practices
Team collaboration
Staff education
Communication

31. Identify problems with polices and procedures Example: Pre- and Post-Operative Care
Problem Area
Recommendation
Eliminate shaving of skin the night before surgery
Single dose peri-op antibiotic prophylaxis guidelines
Use individual sterile packs of wound care instruments
Use small containers of antiseptics; clean and dry containers before refilling
Skin shaved the night before surgery
Inappropriate peri-op antibiotic prophylaxis
Instruments used for dressing changes submerged disinfectant
Large containers of antiseptics, no routine for cleaning and refilling

32. Methods to reduce cost of nosocomial infections
Reduce incidence
Reduce morbidity
Shorten hospital stay
Reduce costs of treating infections
Reduce costs of preventative measures
Stop ineffective control measures

33. Eliminate waste Example: Unnecessary nursing techniques
Dressing change of aseptic wounds
Daily dressing change of venous catheter dressings
Daily change of intravenous infusion sets
Preoperative shaving
Routine changing of urinary catheters
Twice daily urinary catheter care
Protective gowns except for care of infected patients
Daschner, F. J Hosp Infect (1991) 18, 73-78)

34. Eliminate waste: Unnecessary microbiologic monitoring
Routine environmental cultures of walls, floors, air, sinks, or other hospital surfaces
Routine cultures of healthcare workers nose and hands
Clinical cultures which are not available to clinicians in time to help with decision making
Also: Failure to generate annual summary of culture data to provide clinicians with data for empirical selection of antibiotics

35. Cultures of Walls, Floors and Other Smooth Surfaces
All hospitals have some bacterial colonization of environment
What is the evidence that the environment directly infects the patient?
Hospitalized patients infect the environment
Poor technique, poor handwashing, poor disinfection have all been shown to infect the patients but these are all related to poor practice not the environment directly
Floors, Walls, Tables, Beds etc. should be cleaned properly but not cultured

36. Environmental Culturing: U. of Wisconsin Hospital Experience
While maintaining standard hygiene and cleaning, degree of
environmental contamination had no effect on infection rate

37. Prolongation of Hospital Stay due to Nosocomial Infections in the USA
Adapted from Dixon, Ann Int Med 89:749, 1978

38. Annual Costs and Benefits of Infection Control Program in a Hypothetical 250-bed Hospital
Each $1000 invested in infection control
will return $3000 in net direct cost savings

39. Annual Nosocomial Infection Cost Savings by Introducing Effective Infection Control Program to a 250-bed Hospital

40. Antibiotic Prophylaxis in Surgery
Potentially an important part of surgical wound infection prevention
May also be a significant expense for the hospital
What is the cost-benefit of prophylactic antibiotics?
What is cost of wound infection? In money? In suffering?
How effective is prophylaxis?
How much can we spend to prevent a case of wound infection ?

41. Cost of Surgical Prophylaxis with Cefonocid in a Boston Teaching Hospital
Assuming $10 per course:
$178 to prevent one breast infection
$539 to prevent one herniorrhaphy infection
$1,515 to prevent one readmission for breast infection
$622 to prevent one readmission for herniorrhaphy
From: Platt et al. NEJM 322:153, 1990.

42. Impact of Cefonocid Prophylaxis (per 1,000 patients)
Routine use for breast surgery would prevent
56 infections
23 definite wound infections
16 UTIs
Routine use for herniorrhaphy would prevent:
19 infections
13 definite wound infections
from: Platt et al. NEJM. 322:153,1990.

43. Organization and support
A. Institutional support
Infection control as a department
Placement in the organization
Authority
Personnel
Other resources

44. Organization and support
B. Infection control committee
membership
support by the medical staff
participation by other disciplines
annual planning

45. Organization and support
C. Infection Control Program
quality assessment
information for clinicians
educational/informational resource
surveillance data
outbreak investigation
assurance of appropriate asepsis, sterilization, disinfection
minimize risk from invasive procedures/devices
use of isolation
occupational health