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Report
Hospital Epidemiology
What is it and what is it good for?
Edward O’Rourke, M.D
Harvard University Harvard Medical School
1
"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
2
Nosocomial infection =
Any infection that is not present or
incubating at the time the patient is
admitted to the hospital
3
History of infection control and hospital epidemiology
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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
5
Consequences of Nosocomial Infections
Additional morbidity
 Prolonged hospitalization
 Long-term physical, developmental
and neurological sequelae
 Increased cost of hospitalization
 Death

6
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
7
What is hospital epidemiology?
The fundamental roles of hospital
epidemiology are to:
– Identify risks
– Understand risks
– Eliminate or minimize risks
8
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?
9
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

10
Responsibilities of the Infection Control Program
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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
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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
11
Areas of interest to a hospital epidemiologist

Surveillance for
nosocomial infection
–
–
–
–
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bloodstream infections
pneumonia
urinary tract infections
surgical wound infections
Patterns of transmission
of nosocomial infections
Outbreak investigation
Isolation precautions
Evaluation of exposures
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Employee health
Disinfection and
sterilization
Hospital engineering
and environment
– water supply
– air filtration

Reviewing policies
and procedures for
patient care
12
Areas of interest to a hospital
epidemiologist
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
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Antibiotic use
Antibiotic resistant
pathogens
Microbiology
support
National
regulations on
infection control


Infection control
committee
Quantitative
methods in
epidemiology
13
Organizational topics in hospital
epidemiology
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Relationship of Hospital to
External Agencies and
Organizations
Personnel
Who does the hospital
epidemiologist report to?
Authority
Resources
14
Authority of Infection Control Program

Accreditation mandates: Must meet for
accreditation (example in USA: JCAHO)
– Infection Control Program
– Infection Control Committee
– Authority statement
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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
15
QI versus Regulatory Strategies in
Infection Control
Regulatory approach
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External organizations
establish rules and
regulations
Data collection for
comparison with outside
standards
Inspections for
compliance
Penalties for noncompliance
TQM/QI approach
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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
16
Organizing for Infection Control
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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
17
Changes in Nosocomial Infection Rates in
Hospitals with or without Effective Programs
Infection site and
patient risk
Hospitals with very
effective programs
Hospitals with
ineffective programs
Surgical Wound
High risk
Low risk
Urinary Tract
High risk
Low risk
Pneumonia
Surgical patients
Medical patients
Bloodstream
All patients
%
-48.0
-23.6
%
+13.8
+21.3
-35.8
-41.6
+18.5
+30.7
-7.3
-7.7
+9.3
+10.0
-27.6
+25.5
SENIC Study, CDC
18
Essential Components of an Effective
Infection Control Program (after SENIC)
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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)
19
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
20
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
21
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
22
Key elements of surveillance
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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
23
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
24
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
25
Infection Control Committee
Qualifications to be on the committee
– Interest
– Represent group in hospital
– Experts in their field
– Diplomatic
– Good communicators
26
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
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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
28
Risk factors for surgical wound infection
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Age
Obesity
Malnutrition (low albumin)
Diabetes
Steroids/immunosuppression
Prolonged pre-op
hospitalization
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Infection at another
site
Prolonged procedure
Drains
Urgency of surgery
Foreign body
Skill of surgeon
29
Strategies to develop effective
patient care practices
Team collaboration
 Staff education
 Communication

30
Identify problems with polices and procedures
Example: Pre- and Post-Operative Care
Problem Area
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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
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
31
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

32
Eliminate waste
Example: Unnecessary nursing techniques
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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)
33
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

34
Cultures of Walls, Floors and Other Smooth
Surfaces
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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
35
Environmental Culturing:
U. of Wisconsin Hospital Experience
O ld H o s p ita l
N e w H o s p ita l
N e w H o s p tia l
1979
1979
1980
# P o s itiv e C u ltu re s
N o s o c o m ia l In fe c tio n R a te
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
37
Annual Costs and Benefits of Infection Control
Program in a Hypothetical 250-bed Hospital
Estimated reduction of direct
costs from infections
prevented
Estimated infection control
program expenses
$246,700
Hospital savings
$186,700
$60,000
Each $1000 invested in infection control
will return $3000 in net direct cost savings
38
Annual Nosocomial Infection Cost Savings by Introducing
Effective Infection Control Program to a 250-bed Hospital
Infection site
Infections
without
any
program
Infections
with
effective
program
Infections
prevented
Average
cost per
infection
$
Total
savings
$
Surgical wound
Urinary tract
Respiratory
Bacteremia
Other sites
186
283
74
34
136
120
195
58
22
92
66
88
16
12
44
1944
318
1540
2268
1113
128,304
29,574
24,640
15,216
48,972
TOTAL
713
487
226
$246,706
39
Antibiotic Prophylaxis in Surgery
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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 ?
40
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.
41
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.
42
Organization and support
A. Institutional support
– Infection control as a department
– Placement in the organization
– Authority
– Personnel
– Other resources
43
Organization and support
B. Infection control committee
– membership
– support by the medical staff
– participation by other disciplines
– annual planning
44
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
45

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