The Children's Hospital Colorado epidemiology and infection prevention staff. Back row: (left to right): Kelly West, Samuel Dominguez, Chris Nyquist, James Todd, Becca Bartles, Susan Dolan, Jason Childs; Seated: left to right: Kellie Briley, Sarah Parker.
By Kelly M. Pyrek
One of the most important relationships that infection preventionists can cultivate is with their institution's epidemiologist. It's a partnership that is equally appreciated by the epidemiologist who shares the objective of good patient outcomes. It's an alliance that dates back to 1985, when the SENIC Project provided scientific evidence that infection control programs with qualified IPs and hospital epidemiologists could prevent nearly one-third of healthcare-associated infections (HAIs).
According to Scheckler, et al. (1998), in 1996, the Society for Healthcare Epidemiology of America (SHEA) established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in hospitals. The recommendations address managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines, and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of healthcare workers; personnel resources; and non-personnel resources. More than 18 years later, these responsibilities remain as critical and relevant as ever.
Susan Dolan, RN, MS, CIC, who works in epidemiology and infection prevention for Children’s Hospital Colorado, knows the importance of the IP/Epi relationship in addressing these key issues, having been in her role since 1994 and experiencing first-hand the benefits of working together to achieve congruent institutional objectives. She points to her own healthcare system as an example of how individuals with different backgrounds and specialties can come together to champion the common cause of quality and cost-effective patient outcomes.
Within the Children's Hospital Colorado system there are four infection preventionists -- two nurses and two medical technologists with advanced public health educations who form the core team along with several infectious diseases physicians and a data manger. "We have four ID physicians doing part-time infection prevention and control work. Chris Nyquist, is the medical director of infection prevention and control, Sam Dominguez, is our microbial epidemiologist, Sarah Parker oversees antimicrobial stewardship, and Jim Todd, is the epidemiology department head with a large focus on data and electronic systems streamlining. Kelly Pearce, our data manager, provides the expertise in data management, streamlining and presentation. Each member of the team has a unique background that works well because we are utilizing and building upon the strengths of each of those individuals."
Dolan says she believes the cornerstone of a solid IP/Epi partnership is the infection control risk assessment and plan, "because that is where you will identify what the needs of the program are at your facility, and then tap into the expertise and the resources that you have to address them," she explains. "Whether it's an epidemiologist or a medical director or another healthcare provider, try to determine who can help you address the issues that you have decided to prioritize at your institution. Once you have identified who those people are, it is important to remember that we all ultimately have a common goal -- whether we are in epidemiology or another department -- and that is the best care for the patient. When there are different perspectives among the team, it's helpful to focus on the fact that everyone has the patient and their best interests at heart. That should help with many barriers you might experience when attempting to bridge communication gaps and divergent ideas while fostering strong partnerships."
Those partnerships form the heart of an effective infection prevention program, whose structure Sydnor and Perl (2011) describes as including "either a trained infection control professional or a hospital epidemiologist in charge of the program, IPs, surveillance personnel, secretarial staff, and computer support personnel for the management and analysis of data. Microbiology laboratory support is crucial to the functioning of an infection control program. If the microbiology laboratory is unable to perform molecular typing of organisms, a reference laboratory is needed. The hospital epidemiology and infection control program must work with a multidisciplinary infection control committee comprised of leadership from different departments within the healthcare facility. Support from hospital administration and the executive board is imperative to the success of a hospital epidemiology and infection control program. Similarly, there must be an infection control culture and enthusiasm at all levels of the institution."
Sydnor and Perl (2011) point to the SENIC study that found that infection control programs headed by physicians with interests in hospital epidemiology had overall lower rates of HAIs: "Current participation in the NHSN requires that hospital epidemiology and infection control programs be headed by a trained infection control professional or a hospital epidemiologist. Most hospital epidemiologists are physicians trained in internal medicine or pediatrics with subspecialty training in infectious diseases. In a recent survey of 289 hospitals participating in the NHSN, registered nurses led 66 percent of infection control programs, and physicians led only 12 percent of programs. Of those programs with hospital epidemiologists (49 percent of programs), the majority were physicians, but only 10 percent reported working full time as a hospital epidemiologist. These findings coupled with results of the SENIC study and an ever-expanding and more complex healthcare system suggest a great need for hospital epidemiologists in order to achieve significantly lower rates of HAIs."
Physician engagement is key to exacting a high degree of benefit from the epidemiologist/infection preventionist collaboration. "I recommend that IPs do some intentional knowledge sharing with physicians, and find out what their interests are in their field," Dolan says. "Hopefully IPs are reading relevant journals so when they see something that might be of interest to their colleague, they can share it with them. It may also be helpful to glean what research interests they have and also determine what their strengths are. For example, ask if you can attend their patient rounds or ask if you can discuss a specific case or issue. When you are reviewing a paper and you are stuck on something such as wondering if it is a strong enough paper to help drive change in your organization, ask them to review the paper with you or take time to discuss it. If they happen to have a patient conference where infectious-diseases cases are discussed, ask if you can attend to learn about key issues they are facing in the patient’s care management. You will be surprised how often infection control questions or concerns arise at which time you can provide real expertise. There is also the information you might have to offer when they are discussing a case that is reportable to the health department, or has other infection control implications. It's important to try to understand their world and to also do some intentional knowledge sharing with them."
Dolan says that IPs can keep this knowledge-sharing in mind when they attend conferences and meetings. "Sometimes you attend a conference and think to yourself, 'What will I learn/' but maybe you can also ask yourself, 'What can I take back to different people at my institution that will be relevant to their work?' I just did that at the SHEA Spring Conference. About a year ago we had asked our GI team if they were considering fecal microbiota transplants (FMT) in their program. At that time, it wasn't currently on their list of priorities. At the SHEA meeting, I attended a great presentation by Dr. Michael Edmondon on FMT, which was very helpful for anyone thinking about establishing a fecal transplant program. At a patient ID conference at my facility the following week, the docs were actually discussing fecal transplant as a potential option to consider for a previous patient, so I shared with them information about the presentation I had attended. The patient did not end up having a fecal transplant for various reasons, but I communicated that it was important for infection prevention to know they were considering this option, as we currently don't have a process in place for carrying out the procedure. As a result, that created the opportunity for us to reach out again to GI, engage in a discussion of the current status/interest, and now we are moving forward with developing a process by utilizing the information gleaned from that SHEA meeting. It's a good example of how I was able to bring information back to the Dr. Dominguez, our microbial epidemiologist who has research interests and expertise in pediatric C. difficile. Until I attended that presentation, we actually were unaware that there was a stool donor bank option available as well, and what advantages this could potentially provide us, if regulatory-wise we are able to utilize that as an option in our process. We are moving forward with drafting a protocol for fecal transplants and various members of the working group are each taking a piece of responsibility for this project."
Because the challenges faced by infection preventionists are many and varied, Dolan suggests creating as wide a network as possible. "Who are epidemiologists' partners as well? It's not just knowing your own facility's epidemiologist but finding out who are the other such experts in your region," she says. "If you are at a professional meeting, be sure to introduce yourself to others. For example, the networking opportunities at the SHEA Spring Conference were fabulous. At lunch I sat at a table with a physician from New Mexico; she is the epidemiologist at a facility there and I think I actually spoke on the phone with her about six months ago regarding patients from that facility that were being transferred to our hospital for a variety of higher-level care issues. It was fortuitous that I met that person so now when I am speaking with my attending physicians at our facility about these patients, I can share I met the epidemiologist at that hospital and some of the ideas we identified would positively contribute to patient transfers, such as knowing about certain important organisms, etc. The networking is also not just with your own local IPs and epidemiologist but also extends beyond to others you may know and respect in the epidemiology field. Physicians do this from time to time. If they know an outside expert on a certain virus, bacteria, or disease they may consult them to get the best information they can in order to make better decisions for their more complicated patients. We also do this within our own facility when we collaborate with experts from other departments. For example, one does not work on a protocol for fecal transplant without meeting with the GI docs who are the expert in knowing which patients need them, etc."
This kind of consultation can also be achieved within the infection control committee, which is comprised of individuals with leadership and clinical positions within the healthcare institution. According to Sydnor and Perl (2011) this committee "serves as a liaison between the infection control and prevention program, hospital patient care and supporting departments, and the hospital administration. Each infection control and prevention program should meet regularly with the infection control committee, and the committee should report to the medical board or medical advisory committee. Ideally, a physician leader should chair or co-chair the infection control committee. The hospital epidemiologist often fills one of these roles. Committee membership should be multidisciplinary and include representation from IPs, the microbiology laboratory, the pharmacy, operating room staff, occupational and employee health, environmental services/housekeeping, engineering facilities, central processing, hospital administration, and physician and nursing leadership from various clinical and support departments."
Sydnor and Perl (2011) add that the roles of the infection control committee include "reviewing surveillance data and drafting intervention plans where necessary, formulating and approving infection control policies, reviewing outbreaks and formulating a response, approving the yearly goals and objectives of the infection control program, developing policy regarding public reporting, and advising the medical and senior administration of the facility. The infection control committee is truly the voice of the infection control and prevention program within the healthcare facility."
The infection control committee can also be a place to learn about other stakeholders' responsibilities and contributions to the institution's operations. "Sometimes we don't know each other's jobs, and that is why I advise taking the time and getting to know what they do -- be a sponge," Dolan says. "Many people, including physicians, like to teach, so let them know what you need from them. This can also work the other way. For example, IPs usually perform the day-to-day surveillance and are familiar with the NHSN definitions, and yet this may be unfamiliar territory for many epidemiologists. IPs can help them understand that these aren't clinical definitions but are surveillance definitions, and they don't have to know all of the ins and outs of them. IPs can instead work with their epidemiologists on understanding things such as the surveillance basics, data outcomes, which national guidelines you utilize routinely, what new products are pertinent, and where the significant gaps are in your system."
One of the most significant challenges shared by IPs and epidemiologists is number crunching to identify rates of HAIs, rates of infection or colonization with epidemiologically important organisms, and rates of relevant processes of care such as compliance with hand hygiene. Surveillance has taken on new meanings in the era of healthcare reform, where transparency in the healthcare system is expected, facilitated in part by legislation requiring that healthcare facilities report rates of HAIs, rates of infection and colonization with epidemiologically significant organisms, and rates of process-of-care measures to public health authorities or other agencies that can publicly display the data.
As Sydnor and Perl (2011) explain, "Surveillance data are used to identify problem areas where infection prevention and control measures should be instituted, with the goal of improving patient safety. Surveillance is truly the cornerstone of hospital epidemiology and infection control programs, as it highlights where these programs should focus their energies and allows programs to evaluate the effectiveness of their infection control efforts." They add, "In addition to meeting regulations and guidelines, surveillance serves multiple other roles important for an infection prevention and control program. Surveillance can be used to establish baseline infection rates, detect outbreaks, convince clinicians and administrators of potential problems, affect hospital policy, assess the impact of interventions, guide antimicrobial stewardship practices, conduct research, reduce HAI rates, and make comparisons of rates and practices within and between hospitals. Another important application of surveillance is the monitoring of process measures. Process measures are evidence-based interventions or procedures known to decrease HAIs. Examples of surveillance based on process measures include vaccination rates among HCWs, rates of compliance with recommended hand hygiene, and rates of compliance with surgical antibiotic prophylaxis. Process measure surveillance provides information on what infection control measures should be the focus of prevention efforts."
"As epidemiologists and infection preventionists we need to constantly prioritize our regulatory, accreditation and collaborative efforts in conjunction with all the things our organizations want us to do. That requires data, and if you are lucky enough to have a data person to determine the best way to share data in ways that are meaningful, it makes it easier," Dolan says. "Now that more facilities are moving toward electronic records, we need better strategies to retrieve data that is usable, and in a format that can decrease the amount of manual chart review – and yet despite electronic charts, IPs may still need to perform some level of chart review and data massage. That's been a recent focus for us -- Dr. Todd is working with Kelly Pierce our data person and together, with input from IPs, they are driving the movement toward adopting an electronic surveillance system with interfaces and streamlines the data. They have been involved on the front end by utilizing the expertise of our IT folks, in conjunction with IPs, and developed a successful business case to address this need for the program. The validation phase of the project is next and will involve expertise of the IPs in moving this process into our daily workflow.."
This kind of coordination and collaboration can serve not only day-to-day operations but can function as the cornerstone of communication during a potential outbreak scenario. As Sydnor and Perl (2011) explain, "An outbreak is defined as an increase in the incidence of a particular disease over the baseline expected incidence. Five percent of HAIs occur as epidemics or outbreaks. During outbreaks of HAIs, the infection either is usually spread from a common source or from person to person or is associated with specific procedures. Outbreak investigations often provide critical information about the epidemiology of important pathogens. They have led to the identification of new routes of infection transmission in healthcare settings and enhanced measures to improve patient safety. Electronic data and surveillance systems and expanded molecular typing methods that determine organism relatedness have improved our ability to recognize outbreaks of HAIs."
Epidemiologists and IPs are key to reviewing all available information to confirm the presence of an outbreak. As Sydnor and Perl (2011) note, "This requires comparing current rates with previous rates and determining if there is clustering in time or space. If an outbreak is confirmed, the next step is to create a case definition, verify the diagnosis, and then determine the nature, location, and extent of the problem ...After the initial investigation is under way, the next steps involve generating hypotheses about disease transmission and risk factors. These hypotheses should then be tested with comparative studies and supported by using microbiological studies. The final step in an outbreak investigation is communicating the results of the outbreak investigation to involved departments and implementing definitive control measures ... Outbreaks of HAIs increase morbidity, mortality, hospital costs, and liability. The recognition and investigation of outbreaks of HAIs are two of the most important activities of a hospital epidemiology and infection prevention and control program. Such investigations can lead directly to improved patient care and patient safety by assessing practices and policies while simultaneously expanding medical and epidemiological knowledge."
"Our infectious disease physicians and fellows will come to us fairly frequently if they think they have detected something of importance as it relates to infection prevention and control," Dolan says. "They have learned -- through ID conferences and through micro rounds, for example -- about what type of things we need and they will come to us and say 'Hey, we have a case of a communicable infection and I know you need to report it to the health department.' They are proactively coming to us and that is because they have learned what our role is and what the IPC program entails. There is positive overlap between epidemiology/infection prevention and the infectious diseases program and without that, you wouldn't have as good of knowledge-sharing and open communication about suspected issues. For example, in the Bacillus outbreak associated with alcohol pads that occurred at our facility in 2011, it was our sharing at micro rounds that we were concerned about seeing more Bacillus and that it didn't make sense. Subsequently, Mary “Mimi” Glode was on the ID service at the attending one weekend, saw a case of Bacillus bacteremia, and knew immediately to say something to us. Even though her primary role was consulting on patients, she was “doing surveillance” when she noticed something might be connected to our other case and knew enough to let us know about it. She quickly sent me an email and that jump-started the investigation even further; we already had an initial case and that second case that she noticed helped us to put the puzzle together. It's that kind of teamwork that can help to solve problems quickly."
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