Virginia R. Roth
Bryan P. Simmons
Definition
A healthcare epidemiologist investigates the rates and determinants of adverse outcomes in the healthcare environment with a primary focus on healthcare-acquired infections (HAIs). A healthcare epidemiologist is not solely an investigator but also implements preventative measures to improve outcomes.
History
Healthcare epidemiology has been practiced since the mid-1800s; Nightingale, Semmelweis, Lister, and Holmes all made significant contributions to the field. Modern healthcare epidemiology began in the 1950s in Great Britain when infection control systems were used to address hospital outbreaks of staphylococcal infections. In the 1960s, the American Hospital Association (AHA) formed the Committee on Infections within Hospitals, and the Communicable Disease Center (CDC, now the Centers for Disease Control and Prevention) formed the Hospital Infections Unit. These two organizations supported an organized approach to addressing HAIs in the United States, and the AHA published a manual on prevention of HAIs that was used extensively for almost two decades [1].
Because of the need to organize and promote the scientific basis of hospital infection control programs and to encourage expansion of such programs, the CDC convened the first International Conference on Nosocomial Infections in 1970 [2,3,4]. In 1980, a group of physicians practicing healthcare epidemiology formed the Society for Hospital Epidemiology of America (SHEA), now called the Society for Healthcare Epidemiology of America (see Chapter 11). Similar organizations were formed in other countries. The first hospital epidemiologists concentrated their efforts on preventing HAIs, and the landmark Study on the Efficacy of Nosocomial Infection Control (SENIC) project reinforced their efforts by demonstrating that a physician specially trained in infection control could reduce the HAI rate [5]. The boundaries of hospital epidemiology have now expanded beyond infection control into clinical performance, quality management, and disaster planning. Furthermore, the settings in which healthcare epidemiology is practiced have now expanded beyond hospitals into long-term care, continuing care, outpatient and ambulatory care, and community-based settings.
Roles and Responsibilities
Healthcare epidemiologists play a key role in the prevention and control of adverse healthcare outcomes with a particular focus on HAIs. This is accomplished through surveillance, outbreak investigation, quality management and patient safety initiatives, educational programs, research, and committee representation (Table 2-1). The healthcare epidemiologist usually works alongside one or more infection control professionals (ICPs) and may be responsible for administering the infection control program. The healthcare epidemiologist also is responsible for maintaining close communication with other programs within the healthcare environment as well as public health and governmental agencies. More recently,
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healthcare epidemiologists have been involved in contingency planning for pandemics and other disasters.
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TABLE 2-1 |
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Surveillance
Surveillance is one of the single most important functions of the healthcare epidemiologist [5]. As more jurisdictions mandate public disclosure of HAI rates, healthcare epidemiologists are increasingly being called on to design and implement mandatory reporting systems and monitor their results [6] (see Chapter 15). The primary objectives of surveillance are to identify problems for correction, order priorities, and take measures to reduce adverse outcomes (see Chapter 4). The healthcare epidemiologist is responsible for setting surveillance priorities and overseeing data collection, analysis, interpretation, and reporting. When possible, surveillance methodology should be consistent with national or international surveillance systems to allow for benchmarking. Surveillance data are most useful when compared against historical rates within the same facility or against national benchmarks. It has been suggested that many HAIs are preventable [7], and several centers have shown that multifaceted system interventions can reduce central line–associated bloodstream infections and ventilator-associated pneumonia rates to almost zero [8,9]. The healthcare epidemiologist should lead multidisciplinary intervention teams to implement the system changes necessary to reduce infection rates.
Outbreak Investigation
The healthcare epidemiologist plays a key role in confirming the existence of an outbreak and overseeing data collection, data analysis, and implementation of control measures by the outbreak management team. As part of the outbreak investigation, the healthcare epidemiologist should determine what patient and environmental testing is required and assist in interpreting the results. Additional responsibilities during an outbreak include communication with administrators, physicians, the local public health department, and the media.
Quality Management and Patient Safety
Many healthcare epidemiologists have become involved in quality management and patient safety initiatives because epidemiology is as useful to these areas as it is to infection control (see Chapter 14) [10,11,12]. Continuous quality improvement (CQI) programs depend on data management and statistical analysis that can be provided by healthcare epidemiologists [10,13]. The healthcare epidemiologist also can expand into other areas of quality management, such as clinical practice guideline development [14]. The use of such guidelines can minimize unwanted practice variation and healthcare costs. The tools of CQI also can be applied to infection control programs to reduce the rate of endemic infections, which constitute the majority of HAIs [15,16] (see Chapter 30). Finally, the U.S. National Healthcare Safety Network (formally the National Nosocomial Infections Surveillance System, or NNIS) demonstrates the value of a national surveillance system in promoting patient safety [17].
Education Programs
Good infection control practices can reduce both patient and provider risk of HAIs [18,19]. Unfortunately, healthcare providers often fail to follow these basic practices, and compliance among physicians is generally much lower than among other providers [20,21,22,23,24,25,26]. Several recent studies have shown an alarming lack of infection control training and knowledge in this provider group [27,28,29,30]. The healthcare epidemiologist is in a unique position to promote and reinforce proper infection control measures among physicians and medical trainees. In academic settings, healthcare epidemiologists are often responsible for providing formal infection control training to infectious diseases residents and other physicians. Finally, the healthcare epidemiologist should support and promote the development of an infection control orientation and training program for all healthcare personnel.
Research
Healthcare epidemiologists have a well-established history of identifying and quantifying infection control measures that reduce adverse patient outcomes. The infection control literature accounts for many of the patient safety practices for which there is strong supporting evidence [31,32]. However, many research gaps have been identified [31,33,34], and healthcare epidemiologists must play a pivotal role in addressing these gaps.
Committee Representation
The healthcare epidemiologist should be an active standing member, and may serve as chair, of the infection
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control committee. This committee is responsible for approving infection control policies, highlighting infection control issues to the medical and senior administration of the facility, and reviewing infection control surveillance and outbreak data to develop an appropriate action plan. In addition to infection control committee membership, the healthcare epidemiologist provides valuable input to other committees including occupational health and safety, product evaluation and standardization, pharmacy and therapeutics (particularly with respect to antimicrobial selection and use), and sterilization/disinfection. Membership on these committees may be on an ad hoc basis. Finally, healthcare epidemiologists provide valuable technical and clinical expertise to national and international committees responsible for developing infection control and patient safety-related guidelines.
Administration of an Infection Control Program
In some settings, the healthcare epidemiologist is responsible for the human and financial resources of the infection control program. These responsibilities include developing and implementing the program's goals and objectives, recruiting and selecting staff, delegating responsibilities, developing and controlling the budget, and reporting to administration. Administrative responsibilities also include advocating for additional infection control resources depending on local need and ensuring an appropriate reporting mechanism to allow for timely administrative action when infection control issues are identified.
Communication
The healthcare epidemiologist must maintain close communication with all other members of the infection control team. Furthermore, healthcare epidemiology impacts nearly every area of healthcare delivery including medical, nursing, occupational health, microbiology, pharmacy, housekeeping, logistical services, risk management, and patient relations. Thus, the healthcare epidemiologist must maintain good communication with these areas. Informal communication during clinical rounds or hallway conversations is often as effective as formal consultations or meetings. Thus, the healthcare epidemiologist should be a visible and approachable member of the infection control team. Finally, the healthcare epidemiologist should ensure good external communication on infection control related issues. This includes informing the local public health department and the surrounding community of outbreaks, disaster planning efforts, and other infection control issues of general concern. Communication with the general public should be in conjunction with the public relations department.
Disaster Planning
The healthcare epidemiologist should play a lead role in emergency preparedness and response to pandemics, incidents of bioterrorism, natural disasters, and other emergencies [35,36,37]. The healthcare epidemiologist should be involved in developing the healthcare facility's response plan, providing information and education on protective measures for staff, stockpiling of medications and supplies, and ensuring that robust surveillance systems are in place for prompt detection of an emerging infectious disease or potential emergency events or bioterrorism attacks.
Skills and Support Needed
The healthcare epidemiologist needs many skills to succeed (Table 2-2). The discipline of infection control has increas-ingly incorporated epidemiologic principles and statistical analyses that are generally not learned in clinical training. Thus, formal training in healthcare epidemiology has become important. Few countries have established standards or certified training programs for healthcare epidemiology although early efforts are underway in Europe [34,38]. In the absence of training standards, healthcare epidemiologists must have sufficient knowledge and training to be viewed locally as credible authorities on infection control and epidemiology, particularly by physicians and health administrators.
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TABLE 2-2 |
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Epidemiology Skills
The healthcare epidemiologist's most valuable tool is a thorough knowledge of the science of epidemiology and its associated statistical tools. Those who treat hospital epidemiology as a hobby are unlikely to make the impact
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necessary for their healthcare systems to compete in the future. Scientific skills will allow the epidemiologist to prevent infections and other complications and to seek out and eliminate costly but ineffective infection control traditions (ritual) and quality management busywork. These skills also should help in product evaluation and selection. Most new products cost more than the products that they are designed to replace, but few are worth the extra cost. Good epidemiology skills also are needed to present accurate data to the administration and the medical committees in a concise and forceful format. Such data are difficult to ignore and can drive necessary change and improvement.
Leadership Skills
The healthcare epidemiologist requires leadership skills to be effective in the complex healthcare environment. Effecting change and implementing policy, sometimes over the objections of many other physicians and hospital employees, requires an effective leader. Leadership skills are necessary to develop a vision and goals for the infection control program and to foster team building to achieve these goals. Healthcare epidemiologists who are responsible for program administration also require time management, budgeting, planning, and human resource management skills. The healthcare epidemiologist should consider leadership and management training.
Interpersonal Skills
It is essential to know how to interact with people to get things done. The healthcare epidemiologist should be friendly, visible, approachable, and known. The healthcare epidemiologist must have the confidence of the medical staff to persuade physicians to change their ways when necessary. Negotiation skills are a valuable asset because change must often be negotiated rather than mandated. The healthcare epidemiologist must also have the confidence of administration and be able to negotiate the monetary and other support necessary to implement change. It is important that administration be kept informed of the activities, successes, and needs of the infection control department.
Clinical Skills
A clinical background, while not essential, proves very useful to the healthcare epidemiologist. It allows for more seamless integration into the healthcare delivery environment and enhances credibility with physicians and other clinical leaders. It also creates opportunities to interact with, and provide immediate feedback to, other healthcare workers in the clinical setting (e.g., during “ward rounds”) rather than adopting a purely administrative approach.
Infrastructure Requirements
One of the first management decisions a healthcare epidemiologist should make is to determine what support is needed to do a good job. The healthcare epidemiologist is likely to be most effective when surrounded by a team of ICPs and provided administrative support. He/She should report to both a senior administrator (e.g., vice president of medical affairs) and an influential infection control committee [39]. Developing a network of other healthcare epidemiologists through professional societies and scientific conferences is another valuable resource.
Computers and software are very important to the modern infection control program [40] (see Chapter 8). Computers allow management of surveillance data to assess trends and find solutions to problems. Computers can eliminate the need for a retrospective chart review for all but the most complex problem. In addition, computers can be programmed to prevent problems rather than just count them. The healthcare epidemiologist in partnership with the ICP needs to select the best software for the hospital's needs. Thus, the healthcare epidemiologist must be familiar with the advantages and disadvantages of various software programs.
Networks
Infection control networks are becoming an invaluable resource for healthcare facilities without access to a well-trained hospital epidemiologist, particularly at many community hospitals (see Chapter 10). Infection control networks can favorably impact HAI rates [41]. Policies, surveillance techniques, data analysis, education, outbreak investigation, and product evaluations are additional aspects of the infection control program that can be provided effectively by a network [42].
Getting Paid
Some administrators are unwilling to pay for healthcare epidemiology services and consider them part of the duties that the medical staff provides to the hospital through committee activities [43]. However, there is a premium on preventing HAIs and other complications, because they represent a source of monetary loss for the organization (see Chapter 17) [44,45,46]. Haley et al. used SENIC data to devise a formula for calculating cost savings by instituting various components of a well-run infection control program [47]. In addition to the costs saved by preventing HAIs, the knowledgeable hospital epidemiologist can save the hospital money by eliminating unnecessary ritual, controlling unnecessary antibiotic use, and rejecting expensive new products that are not cost effective. In both resourced and underresourced
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countries, these savings can be presented to administration when seeking reimbursement [48]. In many instances, improving the quality of care and reducing adverse patient outcomes is more easily demonstrated than cost savings associated with healthcare epidemiology initiatives. These initiatives also may help negate the legal liability of a healthcare facility in the face of an adverse patient outcome. Thus, quality, not cost, may be the primary incentive for administrators to retain healthcare epidemiology expertise.
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TABLE 2-3 |
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The Future
There will be many opportunities for hospital epidemiologists to apply their skills in the future (Table 2-3) provided that they are willing to adapt to meet the needs created by changing healthcare delivery systems [49,50,51]. This may be especially true for infectious diseases physicians [52,53]. Perhaps the most pressing of these needs will be controlling the spread of multidrug-resistant organisms, but improving quality in the face of declining resources represents a major challenge. Mandated public reporting, emerging infectious diseases (e.g., severe acute respiratory syndrome, or SARS), and pandemic planning have increased demands for healthcare epidemiology expertise. Clearly, the well-trained and experienced epidemiologist will have many challenges and opportunities ahead.
References