Hospital Epidemiology

What is it and what is it good for?

Edward O’Rourke, 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
 1960-1970’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 4
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

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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 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?
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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
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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
 Infection control
 Antibiotic resistant
committee
pathogens
 Quantitative
 Microbiology
methods in
support
epidemiology
 National
regulations on
infection control

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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 TQM/QI approach
 External organizations  Internal organization of
establish rules and hospital staff to develop
regulations goals and methods
 Data collection for  Data collection for internal
comparison with outside review
standards  Continuous efforts to
 Inspections for improve
compliance  Failure belongs to the
 Penalties for non- entire system, not an
compliance 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 hospital’s problems are different
– Every hospital’s 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

Infection site and Hospitals with very Hospitals with

patient risk effective programs ineffective programs
Surgical Wound % %
High risk -48.0 +13.8
Low risk -23.6 +21.3
Urinary Tract
High risk -35.8 +18.5
Low risk -41.6 +30.7
Pneumonia
Surgical patients -7.3 +9.3
Medical patients -7.7 +10.0
Bloodstream
All patients -27.6 +25.5

SENIC Study, CDC 18

 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 27
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

 Age  Infection at another

 Obesity
 Malnutrition (low albumin)
 Diabetes
 Steroids/immunosuppression
 Prolonged pre-op
hospitalization
site
 Prolonged procedure
 Drains
 Urgency of surgery
 Foreign body
 Skill of surgeon

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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

 Skin shaved the night  Eliminate shaving of skin

before surgery the night before surgery
 Inappropriate peri-op  Single dose peri-op
antibiotic prophylaxis antibiotic prophylaxis
 Instruments used for guidelines
dressing changes  Use individual sterile packs
submerged disinfectant of wound care instruments
 Large containers of  Use small containers of
antiseptics, no routine antiseptics; clean and dry
for cleaning and refilling containers before 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 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)
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 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
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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

Old Hospital New Hospital New Hosptial

1979 1979 1980
# Positive Cultures Nosocomial Infection Rate

While maintaining standard hygiene and cleaning, degree of

environmental contamination had no effect on infection rate 36
 Prolongation of Hospital Stay due to
Nosocomial Infections in the USA

Infection Site Excess Days

Surgical Wound 6.0
Urinary tract 1.2
Pneumonia 4.0
Bacteremia 7.0
Other sites 4.2

Adapted from Dixon, Ann Int Med 89:749, 1978

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Annual Costs and Benefits of Infection Control
Program in a Hypothetical 250-bed Hospital

Estimated reduction of direct $246,700

costs from infections
prevented
Estimated infection control $60,000
program expenses
Hospital savings $186,700

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
Infection site Infections Infections Infections Average Total
without with prevented cost per savings
any effective infection $
program program $

Surgical wound 186 120 66 1944 128,304

Urinary tract 283 195 88 318 29,574
Respiratory 74 58 16 1540 24,640
Bacteremia 34 22 12 2268 15,216
Other sites 136 92 44 1113 48,972
TOTAL 713 487 226 $246,706
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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 322:153, 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. 322:153,1990.
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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
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