hospital epdemiology-january 2015 (dr wawang)
DESCRIPTION
epidemiologiTRANSCRIPT
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Dr.dr. Wawang S Sukarya, SpOG (K), MARS, MH.Kes
MAGISTER MANAJEMEN RUMAH SAKIT
UNIVERSITAS ISLAM BANDUNG
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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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Additional morbidity Prolonged hospitalization Long-term physical, developmental
and neurological sequelae Increased cost of hospitalization Death
Consequences of Nosocomial Infections
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Why do we need hospital epidemiology??
Hospitals are complex institutions where patients go to have their
health problem diagnosed & treated
But, hospitals and medical/surgical interventions introduce risks that
may harm a patient’s health
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Challenges to the hospital epidemiologist
Make a hospital safe – Prevent harm to the patient & 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 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– Infection Control Program
– Infection Control Committee
– Authority statement
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 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 andpatient risk
Hospitals with veryeffective programs
Hospitals withineffective programs
Surgical Wound % %High risk -48.0 +13.8Low risk -23.6 +21.3
Urinary TractHigh risk -35.8 +18.5Low risk -41.6 +30.7
PneumoniaSurgical patients -7.3 +9.3Medical patients -7.7 +10.0
BloodstreamAll patients -27.6 +25.5
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 & 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
Age Obesity Malnutrition (low albumin) Diabetes Steroids/immunosuppression Prolonged pre-op
hospitalization
Infection at another 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
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
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
RecommendationProblem Area
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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 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 1979 New Hospital 1979 New Hosptial 1980
# Positive Cultures Nosocomial Infection Rate
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
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 directcosts from infectionsprevented
$246,700
Estimated infection controlprogram expenses
$60,000
Hospital savings $186,700
Each $1000 invested in infection controlwill 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 Infectionswithout
anyprogram
Infectionswith
effectiveprogram
Infectionsprevented
Averagecost perinfection
$
Totalsavings
$
Surgical wound 186 120 66 1944 128,304Urinary tract 283 195 88 318 29,574Respiratory 74 58 16 1540 24,640Bacteremia 34 22 12 2268 15,216Other 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