Quality and Patient Safety Lunch and Learn

VUMC Department of Infection Control and Prevention:

Who We Are & What We Do

April 27, 2011

Healthcare Epidemiology/

Infection Control• Focuses on a variety of disciplines and

activities directed at preventing and controlling infections and adverse outcomes and enhancing the quality-of-care:– Surveillance – Epidemiologic and laboratory investigation – Risk reduction programs – Policy development and implementation – Education and information dissemination

“Public health in

the

hospital”

History: Infection Control Programs

• 1959: AHA establishes advisory committee for nosocomial infection control

• 1962: AHA publishes 1st monograph on hospital infections

• 1969: JCAHO requires infection control committee & a “sanitary environment”

• 1970: CDC establishes NNIS system (19 300 hospitals)

• 1972: APIC founded• 1974: SENIC project• 1975: Half of US hospitals had IC programs/ICPs

Haley RW et al Am J Epidemiol 1985;121:182-205

• Infection surveillance and control programs strongly associated with:– Reduced UTI, SSI, pneumonia, BSI – Adjusted for hospital and pt characteristics

• Essential components of program:– Organized surveillance - Trained MD– 1 ICP per 250 beds - System to

report SSI rates to surgeons

HAI with IC programs: 32%HAI without HAI programs 18%

History: Infection Control Programs

• 1980: SHEA established• 1981: CDC Guidelines for Prevention and Control of

Nosocomial Infections • 1981: CIC established• 1987: Infection control is one of key JCAHO “critical

indicators”• 1992: HICPAC established• 1990s: Era of guidelines• 2000s: Era of QI• 2006: NNIS NHSN system• 2008: CMS and nonpayment for HACs• 2011: HAIs added to IPPS

• Often paired with Infection Control & Prevention programs

• MD Epidemiologist (usually ID certified)• Nurse specialists – Infection

Preventionists• Database analysts• Collaboration with many groups

Healthcare Epidemiology

Healthcare Facility =

VUMC IC Structure Pre-2000

Hospital Epidemiologist

Secretarial Support

ICPs (2)

IC Nursing Coordinator

Administrative Liaison

VUMC IC&P Structure: 2011

Chief Hospital Epidemiologist

Secretarial Support

ICPs (8)

IC Director

VCH Hospital Epidemiologist

Associate Hospital Epidemiologists (2)

Administrative Liaison

Database Analysts (2)

THEN NOW

Cover multiple hospitals

Chair IC Committee

Develop policies

Extinguish fires

QI/Prevention focus

Act as well as track

Growing regulatory needs

Prevent fires

Evolution of IC Programs

THEN NOW

Evolution of HE

Surveillance and epidemiological

principles

Outbreak investigation

Transmission and control of nosocomial

infections

Disinfection and sterilization

Employee health

Quality improvement

Implementation science

Leadership/management

Communication skills

Teamwork

Negotiation

Organizational behavior and group psychology

IC&P: Who We Are

• Vicki Brinsko RN CIC– Director– Yrs of IC Experience:

28; 25 years at VUMC

– Member of HICPAC– Past President, Mid-

TN APIC– APIC Chapter

Legislative Representative

IC&P: Who We Are

• Kathie Wilkerson RN CIC– Yrs of IC Experience: 18– Past President, Mid-TN APIC– CDC Blue Ribbon Abstract

award at APIC 2005– THA Safety Award Abstract

2005– 33 years at VUMC

• Jan Syzchowski RN CIC– Yrs of IC Experience: 18– President, Mid-TN APIC– Past President Western KY

APIC– Gold Medal winner poster

presentation 2008 APIC International Conference

IC&P: Who We Are

• Tracy Louis RN MSN CIC– Yrs of IC Experience: 7– Past President, Mid-TN

APIC– Presented 3 posters at

APIC

• Lorrie Ingram RN BSN CIC– Yrs of IC Experience: 6– Presented poster at APIC– Vast nursing experience

IC&P: Who We Are• Amy Dzewior RN BSN

– Yrs of IC Experience: 3– APIC secretary Med-TN chapter– Presented poster at APIC 2010

• Beth Hodge MS RN – Yrs of IC Experience: 1– Co-authored poster for APIC 2011

International Conference– Featured in “Do No Harm”

conference in May 2011

IC&P: Who We Are

• Jackie Smith RN MSN– Yrs of IC Experience: 3– IPC for MCJCHV

• Tanya Boswell RN MSN– Yrs of IC Experience: 1.5– IPC for MCJCHV

IC&P: Who We Are

• Brian Nelsen BGS CISSP– Data analyst and IC&P

software developer

• Gale Woodland BBA– Newest member of IC&P

Team– Focus on analysis/trends

IC&P: Who We Are

• Peggy Connolly Administrative Assistant

• 25 years in IC&P and at VUMC

• Jonelle Williams - Chart abstraction and assitant to IPCs

• I year with IC&P

IC&P: Who We Are

• Tom Talbot MD MPH– Yrs of IC Experience: 10– Member, HICPAC– Chair, SHEA Education

Cmtee

• William Schaffner MD– Assoc Hosp

Epidemiologist– Chief Hosp Epidemiologist

for 32 years– Yrs of IC Experience: 45– Past President, SHEA– Secretary, IDSA– President, NFID

IC&P: Who We Are

• Titus Daniels MD MPH– Assoc Hosp

Epidemiologist– Chair, Health Records

Exec Cmtee– Co-Director, Vanderbilt

Antibiotic Stewardship Program (VASP)

– Yrs of IC Experience: 6– APIC Annual Conf

Cmtee

• Greg Wilson MD– MCJCHV Hosp

Epidemiologist– Yrs of IC Experience: 4

IC&P: Who We Are

• Jim Johnson MD MPH– Yrs of IC Experience: 1– Joining team as

Associate Hosp Epidemiologist at VUMC

– Williamson Medical Center Hospital Epidemiologist starting July 2011

• Fellows:– Jennie Esbenshade

MD – James Crowe MD– Kyle Widmer MD

A Day with the Infection

Preventionist’s Beeper

8:19am Monday

• The Chairman of Surgery calls you wanting to know the “infection rate” for the surgeons in his department for a presentation he is giving to the unit.

• No worry . . . He needs the data before tomorrow at 6am.

Role of Healthcare Epidemiology I:

Surveillance• Tracking outcomes in a regular,

standardized manner to assess for trends

• The cornerstone of healthcare epidemiology

• How do you know you have a problem w/o data?

Central Line-Associated

Bloodstream Infections

The Problem: Healthcare Associated Infections

Ventilator-Associated Pneumonia

Surgical Site Infections

Cather-Associated Urinary Tract

Infections

Surveillance

• Routine collection of data• Utilize standardized definitions for cases• Utilize common denominator

populations• Allows for assessment and comparison

of rates– e.g. Bloodstream infection rates patients

with a central venous catheter – BSI per 1000 central line days

9:45am Monday

• You receive an email from the Director of Infection Control & Prevention asking you to review the institution’s current policy on isolation of patients with suspected or confirmed contagious infections.

Role of Healthcare Epidemiology II: Prevent Transmission of

Infections• Many patients may be infected with or

colonized with contagious infections• These may be spread by direct contact

with the patient or their environment or through the air

• Must minimize transmission of such pathogens

CDC Transmission-Based Precautions

10:30am Monday

• Meeting with the Central Line Bloodstream Infection Task Force

Role of Healthcare Epidemiology III: Prevention

Initiatives• Develop and implement programs that are

designed to prevent infections using evidenced-based practices

• Synergize skills with those of QCs• Collaborate w/key stakeholders• Make sure have representation of frontline

AND leadership• Decide how you’ll measure the impact

BEFORE implementing the measure

11:07am Monday

• A reporter from the Tennessean contacts you after the release of the first state report on healthcare-associated infection rates.

• She wants a comment as to why your hospital has a higher rate of surgical site infection in cardiac surgical patients than other hospitals in the city. “Why are you guys so bad?”

Role of Healthcare Epidemiology IV: Communicating a

Message/Education• May be within the hospital• May be outside of the hospital• Key = simplifying the message

Nosickfolks Hospital

The Lowest Infection Rates in TN!!!

(Much Lower Than Vanderbilt)

1:07pm Monday

• Nurse from an inpatient unit contacts one of the infection control nurses re: 3 patients in the hospital who developed bloodstream infections with a highly resistant strain of Acinetobacter baumannii. She’s wants to know if you think there is an outbreak in the ICUs.

Function of Healthcare Epidemiology V: Outbreak

Investigation• Identify increased incidence of events above

the baseline rate– ? How many cases = “increased”

• Create a case definition• Find all potential cases• Save isolates• Determine if cases related• Identify risk factors• Implement control measures

Are the Strains Related?

Pt APt B

Pt C

Pt D

Saline Flush

All isolat

es clonally the same

Pt E

Pt F

Both isolates clonally

the same

Pulse-Field Gel Electrophoresis

2:53pm Monday

• Notified by pediatric unit that 3 yr old diagnosed with pertussis (whooping cough). Pt was not placed in isolation on arrival and has been here for 4 days.

Function of Healthcare Epidemiology VI: Contagious

Disease Exposures• Confirm exposure event occurred• Identify exposed patients and healthcare

workers• Evaluate need for post-exposure

prophylaxis

4:03pm Monday

• Called by an ED attending physician• Just examined a 38yr-old corporate

lawyer for Saturn who presented with 5 days of progressive cough, malaise, and fatigue.

• PE: febrile, hypoxic, Ill-appearing

• At the end of your conversation, the MD recalls that the patient stated he felt “great” before leaving for China 10 days ago.

• Pt had been touring areas of China to investigate prospective new factory location for his work. Enjoyed walking through the markets, where there were plenty of chickens loose. Illness began 1 day prior to return.

4:03pm Monday

Function of Healthcare Epidemiology VII: Biopreparedness

Function of Healthcare Epidemiology VII: Biopreparedness

• Work with EP, leadership• Develop of institutional plans

– Personal protection– Patient screening– Adequate supplies– Surge issues– Prioritization for limited resources– Development of stockpiles

• Tabletop and real-time drills

7:23pm Monday

• OR Administrator calls you frantic• Pt underwent brain biopsy last Thursday• Pathology compatible with vCJD (“Mad

Cow Disease”)• Instruments used in case were sterilized

through normal processes– [Which won’t kill the pathogen]

• Have been reused since Friday morning

Function of Healthcare Epidemiology VIII: Crisis

Management

• Selected VUMC IC&P Calls :– De facto OR in Cosmetic Surgery Clinic

• This being used as surgical scrub

– Dirty bronch used on pt– VZV exposure in 7N, psych hospital – VU undergraduate with meningitis– State reporting data on CLABSI

Key Code for IC&P “Speak”

• IPC= Infection Prevention Consultant

• CIC= Certified in Infection Control; this exam must be taken every 5 years to maintain certification

• HICPAC= Health Infection Control Practices Advisory Committee; federal advisory committee made up of 14 infection control experts; serve a 3 year term.