Role of the Hospital Epidemiologist:Role of the Hospital Epidemiologist: beyond infection prevention and control

Mary Vearncombe, MD, FRCPCMedical Director, Infection Prevention and Control

Sunnybrook Health Sciences Centre mary.vearncombe@sunnybrook.ca

Hospital Epidemiologistp p g

Definition:• “anyone who concerns themselves with the

determinants of hospital acquired diseases or i j i ith th l f ti ”*injuries with the goal of prevention”*

• traditionally has referred to infection prevention d t land control

• increasingly applied to clinical performance, lit t d ti t f tquality management and patient safety

* Hospital Infections 4th ed Bennett & Brackman 1998* Hospital Infections 4th ed, Bennett & Brackman 1998

Hospital EpidemiologistHospital Epidemiologist

• traditionally position has been filled by physicians y p y p ywith background in microbiology and/or infectious diseases

• as scope expands, this association may not persist• hospital epidemiology is a science based on

information not generally covered by any other specialty, including micro/ID– epidemiologic principles– statistical analysis

• formal training in hospital epidemiology important

Role of Hospital EpidemiologistRole of Hospital Epidemiologist1. Infection Prevention and Control2 Clinical Performance Assessment and Quality2. Clinical Performance Assessment and Quality

Management3. Occupational Health3. Occupational Health4. Risk Management/Patient Safety5. Microbiology Laboratory Liaisongy y6. Pharmacy Liaison7. Facility Standards, Construction and Renovationy ,8. Provincial/Federal Standards Development9. Emergency Response Planning

1. Infection Prevention and ControlAdministration of the facility IP&C program• surveillancesurveillance• control of endemic infections• outbreak investigation and control• outbreak investigation and control• development of policies and procedures

d l i• new product evaluation• reprocessing• occupational health• education• research

1. Infection Prevention and Control

• collaborate with the infection control practitioner(s)• strategic plan for program:

– hospital’s priorities– high risk, high volume, problem-prone areas– most cost effective strategies

il bl / d d– available resources / needed resources• set goals and objectives, prioritize projects

tb k / id i d th bl i• outbreaks/epidemics and other problems require immediate attention

1. Infection Prevention and Control

Surveillancei l li i• integral to any quality improvement process

• includes analysis of data• to detect problems• to determine endemic and epidemic rates• to set priorities• to develop/revise policies• to monitor results of interventions• visible presence in clinical areas

1. Infection Prevention and Control

Development of policies and proceduresgenerall de eloped primaril b IP&C ser ice• generally developed primarily by IP&C service

• developed in consultation with key stakeholdersd i d i i i i k f i l• designed to minimize risk of nosocomial infection

d h h i• approved through IP&C Committee, MAC• education of staff required for implementation• availability for front-line staff, e.g. intranet• evaluation

1 Infection Prevention and Control1. Infection Prevention and Control

Product evaluation– ensure that new products do not present

risk of infection• e.g. needleless IV systems

– ensure that products marketed to p“reduce” infection are cost-effective• e.g. antimicrobial impregnated catheters

– ensure that products can be and are reprocessed to eliminate risk of transmission of infection

1. Infection Prevention and Control

Reprocessinghi hl l idl l i• highly complex, rapidly evolving area– standards updated frequently

lit it i di t– quality assurance, e.g. monitors, indicators• technology enables ambulatory patient care

equipment complex and expensive– equipment complex and expensive– reprocessing decentralized

knowledge and skills needed– knowledge and skills needed• reuse of single use devices

– infection control and physical integrity concernsinfection control and physical integrity concerns

1. Infection Prevention and ControlReprocessing (cont’d)• all direct patient care and reprocessing equipment p p g q p

should be assessed by infection prevention and control before purchase

d i ll di bl d l i• ensure design allows disassembly and cleaning– manufacturer to provide device specific instructions

• ensure process in place for reprocessing meets• ensure process in place for reprocessing meets PHAC, PIDAC, CSA and manufacturer’s standards– periodic audits

• ensure staff knowledge/skills– training and certification

l li i f i• strongly encourage centralization of reprocessing

2. Clinical Performance AssessmentQ lit M t d P ti t S f tQuality Management and Patient Safety

• epidemiologic principles can be applied to other quality initiativesd ll i d l i i l CQI• data collection and analysis are integral to CQI programs

• patient safety programs, eg. drug errors and adverse events, transfusion errors, lab errors– “safer healthcare now” initiatives: BSI, SSI, VAP– mandatory public reporting: CDI, MRSA and VRE

bacteraemias VAP CL BSI surgical antimicrobialbacteraemias, VAP, CL-BSI, surgical antimicrobial prophylaxis, hand hygiene compliance

– requires resources• clinical practice guideline development

– minimize practice variationreduce LOS– reduce LOS

– reduce costs

3. Occupational Healthp• collaboration with Occupational Health and Safety

to minimize transmission of infections to protectto minimize transmission of infections to protect both patients and health care providers– integral to successful IP&C programg p g

• vaccine programs: hepatitis B, annual influenza, varicella, MMR, DPTP, acellular pertussis (dTap)

• use of personal protective equipment (PPE)• post-exposure management: sharps injuries, TB,

meningococcal disease aricella MMR scabiesmeningococcal disease, varicella, MMR, scabies, pertussis

• return-to-work practices related to infectionreturn to work practices related to infection• “healthy workplace” policy

4. Risk Management• prevention of adverse outcomes using epidemiologic• prevention of adverse outcomes using epidemiologic

principles vs empiric case analysisRisk = Probability x SeverityRisk Probability x Severity– surveillance for estimate of events using sensitive/specific

definitionl ti f d i t– selection of denominator

– severity of injury• investigation of “sentinel” eventsinvestigation of sentinel events

– e.g. unanticipated death due to nosocomial infection• root cause analysisy• evaluation of infection control issues related to litigation• having evidence-based, current policies and procedures

in place may mitigate liability

5. Microbiology Laboratory Liaisongy y• rapid diagnosis of infection• infection surveillance• infection surveillance

– routine and prevalence screeningdetection of “sentinel” organisms– detection of sentinel organisms

– outbreak investigation• “cascade” antimicrobial reporting to influencecascade antimicrobial reporting to influence

utilization and reduce development of resistance• monitoring antimicrobial susceptibility patternsg p y p• epidemiologic typing

– e.g. molecular epidemiology• laboratory biosafety

6. Pharmacy Liaisony

• application of epidemiologic principles for ill f di i d dsurveillance of medication use, errors and adverse

eventsl ti f ti i bi l f l d• selection of antimicrobial formulary and

restriction of specific antimicrobials to reduce resistanceresistance

• antimicrobial prophylaxis regimens– e g SSI prevention; influenza outbreak managemente.g. SSI prevention; influenza outbreak management

• prevent infections, decrease side effects, reduce costs

7. Facility Standards, Construction, Renovation• environmental organisms present risk to patients during

facility construction, renovation– e g Legionella Aspergilluse.g., Legionella, Aspergillus

• risk dependent on level of disruption and level of patient immune compromise

• IP&C involved with facilities planners and maintenance– identification in gaps from standards (CSA, AIA)

• e g spacing ventilatione.g. spacing, ventilation– identification of design “barriers” to IC practice– design of new/renovated facilities

• e.g. 80% single rooms in new construction– containment during construction/renovation

response to identified problems/disasters– response to identified problems/disasters• e.g. mould abatement, flood management

8 Provincial/Federal Standards Development8. Provincial/Federal Standards Development

• Public Health Agency of Canada InfectionPublic Health Agency of Canada Infection Prevention and Control Guidelines Steering CommitteeCo ttee

• Provincial Infectious Diseases Advisory Committee (PIDAC) Subcommittee onCommittee (PIDAC) Subcommittee on Infection Prevention and Control

9. Emergency Response Planning

• internal and external disaster response• biologic components of CBRN disasterbiologic components of CBRN disaster

responsefacility municipal provincial federal– facility, municipal, provincial, federal levels

d i i fl l i d– e.g. pandemic influenza planning and response; SARS response

Skills for the Hospital Epidemiologistp p gKnowledge of the science of epidemiology and statistical

toolstools– prevent infections and other complications through

evidence based practiceevidence-based practice– eliminate costly but ineffective (ritual) practice

present accurate pertinent data to administration and– present accurate, pertinent data to administration and MAC to drive change and practice improvement (e.g. SSI rates, ARO rates, HH compliance)SSI rates, ARO rates, HH compliance)

• specific formal training (e.g. SHEA/CDC course)• CME: journals (e g ICHE J Hosp Inf)• CME: journals (e.g. ICHE, J Hosp Inf)

annual meetings (e.g. SHEA)

Skills for the Hospital Epidemiologist

Management Skills• planning and setting prioritiesp g g p• developing policy• effect change and implement polic• effect change and implement policy• CQI tools• budgeting

Skills for the Hospital Epidemiologist

“People” skills• visible approachable knownvisible, approachable, known• collaborative with ICPs CIC certified

fid f di l ff• confidence of medical staff• confidence of administration• Infection Prevention and Control Committee

– ± Chair± Chair

“All hospitals sho ld ha e the contin ing“All hospitals should have the continuingservices of a trained hospital epidemiologist”

• Category I, SHEA Position Paper, 1998ICHE 19:114-124ICHE 19:114 124

• Naylor and Walker reports• PIDAC Recommendations for IP&C Programs in f g

Ontario, 2008• dependent on size, complexity of institution• regionalization or consortium approach for smaller or

community facilitiesR i l I f ti C t l N t k (RICN )– e.g. Regional Infection Control Networks (RICNs)