Hospital Epidemiology

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Hospital Epidemiology

• What is it and what is it good for?

Edward ORourke, M.D Harvard University -
Harvard Medical School
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"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
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Nosocomial infection Any infection that is
not present or incubating at the time the patient
is admitted to the hospital
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History of infection control and hospital
epidemiology

• Pre 1800 Early efforts at wound prophylaxis
• 1800-1940 Nightingale, Semmelweis, Lister,
  Pasteur
• 1940-1960 Antibiotic era begins, Staph. aureus
  nursery outbreaks, hygiene focus
• 1960-1970s Documenting need for infection
  control programs, surveillance begins
• 1980s focus on patient care practices,
  intensive care units, resistant organisms, HIV
• 1990s Hospital Epidemiology Infection
  control, quality improvement and economics
• 2000s ??Healthcare system epidemiology

modified from McGowan, SHEA/CDC/AHA training
course
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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 patients health

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Consequences of Nosocomial Infections

• Additional morbidity
• Prolonged hospitalization
• Long-term physical, developmental and
  neurological sequelae
• Increased cost of hospitalization
• Death

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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

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What is hospital epidemiology?

• The fundamental roles of hospital epidemiology
  are to
• Identify risks
• Understand risks
• Eliminate or minimize risks

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What is the role of hospital epidemiology?

• Identify risks to patients 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?

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What is the role of hospital epidemiology?

• Eliminate or minimize risks to a patients 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

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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

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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

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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

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Organizational topics in hospital epidemiology

• Relationship of Hospital to External Agencies and
  Organizations
• Personnel
• Who does the hospital epidemiologist report to?
• Authority
• Resources

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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

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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

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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 hospitals problems are different
• Every hospitals personnel are different
• The hospital must develop its own unique program

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

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Personnel

• Hospital Epidemiologist
• 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
• Training in infection control

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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

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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

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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
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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

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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

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Infection Control Committee

• Qualifications to be on the committee
• Interest
• Represent group in hospital
• Experts in their field
• Diplomatic
• Good communicators

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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

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What is Hospital Epidemiology good for?

• Infection control
• Quality improvement
• Controlling costs
• An effective hospital epidemiology program can
  help achieve all three goals

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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

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Strategies to develop effective patient care
practices

• Team collaboration
• Staff education
• Communication

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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

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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

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Eliminate wasteExample 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)
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Eliminate wasteUnnecessary 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

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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

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Environmental Culturing U. of Wisconsin
Hospital Experience
While maintaining standard hygiene and cleaning,
degree of environmental contamination had no
effect on infection rate
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Prolongation of Hospital Stay due to Nosocomial
Infections in the USA
Adapted from Dixon, Ann Int Med 89749, 1978
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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
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Annual Nosocomial Infection Cost Savings by
Introducing Effective Infection Control Program
to a 250-bed Hospital
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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 ?

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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 322153, 1990.
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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. 322153,1990.

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Organization and support

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

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Organization and support

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

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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