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Dr.dr.

Wawang S Sukarya, SpOG (K), MARS,


MH.Kes

MAGISTER MANAJEMEN RUMAH SAKIT


UNIVERSITAS ISLAM BANDUNG

"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

Consequences of Nosocomial Infections


Additional morbidity
Prolonged hospitalization
Long-term physical, developmental
and neurological sequelae
Increased cost of hospitalization
Death

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 patients health

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

What is hospital epidemiology?


The fundamental roles of hospital
epidemiology are to:
Identify risks
Understand risks
Eliminate or minimize risks

What is the role of hospital epidemiology?


Identify risks to patients 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 patients 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

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 noncompliance

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 hospitals problems are different
Every hospitals 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

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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
Problem Area

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
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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 waste
Example: 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

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

InfectionSite ExcessD
ays
SurgicalW
ound 6.0
U
rinarytract
1.2
Pneum
onia
4.0
Bacterem
ia
7.0
O
thersites
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

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programexpenses
Hospitalsavings
$186,700
Each $1000 invested in infection control
will 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

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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
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TENG KYUU

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