The Healthcare Epidemiologist

Virginia R. Roth

Bryan P. Simmons

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 prevention and 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, many of which are member societies of the International Federation of Infection Control (IFIC). 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 healthcare epidemiology have now expanded beyond infection prevention and 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, long-term acute care, continuing care, outpatient and ambulatory care, community-based settings, and even home healthcare.

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 preventionists (IPs) and may be responsible for administering the infection prevention and control program. He or she is also responsible for maintaining close communication with personnel involved in other programs within the healthcare environment as well as with public health and governmental agencies. More recently, healthcare epidemiologists have been involved in contingency planning for pandemics and other disasters.

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. More professional societies outside of infection prevention and control are developing HAI surveillance systems (7). These may produce conflicting data within the same healthcare organization when different definitions for numerator or denominator data or risk adjustment are used. The healthcare epidemiologist should be prepared to respond to these data, to advocate for surveillance methodology that is consistent with national or international surveillance systems, and to ensure anyone collecting infection surveillance data within their organization has the necessary training in infection surveillance. Surveillance data are most useful when compared against historical rates within the same facility or against national benchmarks. The U.S. CDC’s National Healthcare Safety Network (NHSN; formally the National Nosocomial Infections Surveillance System, or NNIS) demonstrates the value of a national surveillance system in promoting patient safety (8). It has been suggested that many HAIs are preventable (9), and several centers have shown that multifaceted system interventions can reduce central line-associated bloodstream infections and
ventilator-associated pneumonia rates to almost zero (10,11). The healthcare epidemiologist should lead multidisciplinary intervention teams to implement the system changes necessary to reduce HAI rates.

TABLE 2.1 The Healthcare Epidemiologist’s Roles

Surveillance
Outbreak investigation
Quality management and patient safety initiatives
Education
Research
Committee representation
Administration of infection prevention and control programs
Consultation and communication
Disaster planning

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 prevention and control (see Chapter 14) (12,13). Continuous quality improvement (CQI) programs depend on data management and statistical analysis that can be provided by healthcare epidemiologists (13,14). The tools of CQI can also be applied to infection prevention and control programs to reduce the rate of endemic infections, which constitute the majority of HAIs (15,16) (see Chapter 31). The healthcare epidemiologist can also expand into other areas of quality management, such as clinical practice guideline development (17). The use of such guidelines can minimize unwanted practice variation, improve outcomes, and reduce healthcare costs. In particular, healthcare epidemiologists are expected to take a leadership role in antimicrobial stewardship (18).

EDUCATION PROGRAMS

Good infection prevention practices can reduce both patient and provider risk of HAIs (19,20). Unfortunately, healthcare providers often fail to follow these basic practices, and compliance among physicians is generally much lower than among other providers (21,22,23,24,25,26,27). Several studies have shown an alarming lack of infection prevention training and knowledge in this provider group (28,29,30

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