Your Friendly Neighborhood Hospital Epidemiologist: Role, Responsibility, and Relationships. Jason Bowling, M.D. UT Health San Antonio

Transcription

1 Your Friendly Neighborhood Hospital Epidemiologist: Role, Responsibility, and Relationships Jason Bowling, M.D. UT Health San Antonio

2 Objectives Review the skills and competencies of an effective hospital epidemiologist (HE) Discuss the day-to-day activities of the HE and interactions in the hospital setting Analyze the relationship of the HE with the Microbiology laboratory and identify important areas of synergy Review the relationship with the Antimicrobial Stewardship program and identify important areas of synergy

3 Important Distinction Friendly neighborhood Spiderman possesses great power Hospital Epidemiologist can serve as a resource does NOT possess super powers Generally wears less flashy outfits

4 What is a Hospital Epidemiologist anyway?

5 Brief Background 1960s: Infection Prevention and Control began 1970s: landmark Study on Efficacy of Nosocomial Infection Control (SENIC) project 1980s: Employee safety, MDROs 1990s-2000s: focus on preventing hospitalacquired infections (HAIs) Today: Infection Prevention data Public reporting Impacts hospital finances Kaye, KS et al. Infect Control Hosp Epidemiol 2015;36:

6 Infection Preventionists Formal certification program: Certified in Infection Control (CIC) APIC has mapped a development pathway - accessed

7 Hospital Healthcare Epidemiologist No formal accreditation Professional organization: SHEA: The Society for Healthcare Epidemiology of America

8 HE Roles Epidemiologist Subject-matter expert Quality and performance improvement leader Regulatory/public health liaison Healthcare administrator Clinician educator Outcomes assessment evaluator and researcher

9 Infectious Diseases Physician Internal Medicine OR Pediatrics Clinical Microbiology Antimicrobial Pharmacology

10 Subject Matter Expert Competency areas: Infectious Diseases/Pathogen transmission Infection Prevention and Control Outbreak Investigation Microbiology and Laboratory Diagnostics Special Populations and Non-acute Settings Antimicrobial Stewardship

11 Day-to-day activities

12 Infection Prevention Employee Health Pharmacy Patients Healthcare Epidemiologist Hospital Administration Public Health Microbiology and Virology Lab Clinicians

13 Standard activities of Infection Prevention Regulatory compliance (TJC, CMS, DHHS, etc) Hand hygiene program PPE Isolation Precautions MDRO monitoring and control MRSA, VRE, C. difficile HAIs: CLABSIs, CAUTIs, SSIs, C. difficile Disinfection and sterilization Preparedness for pandemics Construction monitoring

14 Daily activities Daily meetings with Infection Preventionists Review of new C. difficile infections or other worrisome MDROs Discuss any new HAIs Scheduled device rounds during the week Patients with central venous catheters Patients with indwelling urinary catheters Appropriate indication? Maintenance?

15 Hand Hygiene

16 HAI reports Mandatory reporting to CDC/NHSN and CMS Central line associated bloodstream infections (CLABSIs) Catheter-associated UTIs (CAUTIs) Surgical site infections (SSIs) Colon surgery Abdominal hysterectomy Hospital-onset MRSA bacteremia Hospital-onset C. difficile infection

17 Public Reporting 57 quality measures Determine an overall star rating (1-5)

18 Public Reporting accessed

19 Relationship with Microbiology Lab AKA We re all in this together

20 NHSN: Surveillance Definitions and Reporting - accessed

21 17 PAGES!!!

22 CAUTI Important Notes NHSN uses surveillance definitions Clinicians use clinical definitions Review of CAUTIs at our hospital revealed: Need to improve device utilization and test ordering Our urine collection process had serious flaws!!!

23 Is it really a CAUTI? Urine specimen collection highly variable From bag, port (not cleaned), or appropriately Urine specimen sent to core lab for UA If UA met criteria, then urine culture was performed on same urine specimen sitting in core lab! Microbiology lab key in identifying specimen processing issues Moved to gray top boric acid tubes to prevent overgrowth/contamination due to delays in processing Urine collection process reviewed with Nursing and standardized

24 Hospital-onset C. difficile infections HO-CDI is a national challenge NHSN definition uses lab ID HO-CDI: Positive lab test on or after day 4 Most hospitals have moved to NAAT approach Many providers used EIA for toxins during training One-step? Two-step testing? Conclusion: Lots of provider confusion out there

25 J Clin Microbiol 2017;55: Helpful Reference

26 CDI Diagnostic Testing Review Multidisciplinary meeting with Microbiology, Hospital Epidemiologist, Hospital Admin Our baseline Only unformed stool accepted Repeat testing limited to 7 days after negative We had both a C. difficile toxin PCR test and a multiplex GI PCR test available Micro lab review of diagnostic testing revealed some interesting ordering patterns

27 Ordering Patterns Micro lab review Ordering C. diff PCR first, and when neg, ordering the GI PCR (in next day or two) C. diff weekly surveillance testing Ordering alternative C. diff PCR and GI PCR 3-4 days apart (to work around 7 day limit) Patient tested in ED and again on floor Hosp Epi/Infection Prevention review Many patients were on laxatives Providers were repeating C. diff PCR testing on known positives to clear them from isolation

28 Diagnostic Stewardship GI Multiplex PCR re-named Community-onset diarrhea panel and limited to first 72 hrs C. difficile results on GI PCR suppressed for children < 2 yrs old (with Pedi ID input) Repeat testing on +C. diff PCR prohibited C. diff PCR testing flagged on patients who have received laxative in past 48 hours Can only be ordered by Faculty MD override

29 Provider Education and Reminders

30 A man in his 40s presented with fever, cough, shortness of breath during summer of 2009 (pandemic influenza outbreak). Rapid flu test was negative. Empirically started on antibiotics. Not started on any antivirals. Case Scenario

31 Case Scenario Developed ARDS, sepsis and transferred to ICU. All cultures were negative. Bronchscopy performed Hosp d#12 extended viral culture from bronch wash positive for Influenza A

32 Influenza Testing and Preparedness Each influenza season is unique 2009 pandemic H1N1, H3N2 Diagnostic stewardship key to reserve resources and optimize clinical care Removal of the Rapid Flu test Virology Director and Hospital Epidemiology presented to Lab Utilization committee Despite clear data on suboptimal sensitivity, many providers were upset to lose this option Numerous conversations with providers

33 Notices to Providers Triaging Diagnostic Studies February 2017 January 2018

34 Review of Diagnostic Assays Removal of rapid flu test Multiplex PCR assays: blood, CSF, respiratory, stool MALDI-TOF Hospital Epidemiologist can provide support for the Microbiology and Virology lab for new assays, revised use of existing assays

35 Public Health Concern 24 y/o man transferred from County Jail to EC for evaluation of 3 days of fever, myalgias, and bilateral jaw pain. PMH/PSH: None NKDA, no meds Exam with bilateral, symmetric parotid tenderness/swelling

36 Diagnosis? Assessment Possible mumps Plan Droplet isolation precautions Supportive care On that same day

37 Case #2!! 35 y/o inmate presents with 3 day history of fever and jaw swelling, difficulty eating and swallowing Has had several ill contacts in jail with fever Exam with significant bilateral parotid swelling and tenderness Assessment: Mumps Plan: Droplet precautions, supportive care

38 Good news Same MD admitted both patients He astutely recognized possibility of mumps Droplet precautions started in EC Admitted with proper isolation precautions Diagnostic studies confirmed mumps virus infection

39 Mumps virus Highly infectious Spreads rapidly in close quarters (jail) Incubation period: days from exposure Viral shedding begins prior to symptoms Peak contagion occurs before parotitis Both patients reported +ill contacts Bad news

40 Phone call Dr. Bowling, We have 2 patients admitted from County Jail with presumed mumps. County Jail has: 3784 inmates 1852 employees What should we do?

41 Are those people vaccinated? en.wikipedia.org accessed

42 Action Plan Acute Care Hospital: Both pts placed on droplet precautions in the EC prior to transfer to the inpatient controlled access unit. No secondary cases of mumps occurred in the acute care hospital. Whew!

43 Action Plan Detention Facility (DF): Health Dept notified and provided recs to the DF. Isolation ward created where the 2 admitted inmates had been housed Inmates retained in iso ward for 25 days All contacts of suspected cases received mumps vaccine Even if the exposed person had previously been immunized with 2 doses of the MMR vaccine MMR total vaccines administered to staff and inmates 2 hospitalized patients discharged back to iso ward after 9 days from symptom onset Amongst DF employees, there was only 1 secondary case of mumps

44 Outbreak Investigation

45 Lessons learned To our knowledge, this was the first mumps outbreak described in a detention facility. Necessary confinement of susceptible individuals in this setting makes it particularly vulnerable to an outbreak. Rapid use of droplet isolation precautions in EC was key to preventing any secondary cases in acute care. Receipt of 2 doses of mumps vaccine does not confer complete protection against infection. Mumps virus responsible for this outbreak was determined to be genotype G Same genotype responsible for the large U.S. outbreak in Vaccine strain (derived from genotype A virus) may not be as effective in providing immunity against the serogroup G wild strains.

46 What does this look like to you? A few people were reviewing a difficult to identify isolate on a plate in the lab. Lid was taken off plate to better view. Unfortunately, it was ultimately identified as Brucella species. What needs to happen next?

47 Brucella post-exposure actions Hospital Epidemiology discussions with Microbiology lab, Infection Prevention, Employee Health Clinic Confirm exposure, identify exposed Everyone within 5 feet of the isolate when it was manipulated Plan provided to Employee Health clinic on monitoring and PEP Doxycycline and rifampin x 3 weeks Symptom and fever monitoring Serological monitoring 0 (baseline), 6, 12, 18, and 24 weeks No conversions!

48 Screening To screen or not to screen? Decisions to screen must be tailored to facility Guidelines and data often ambiguous community standard of care might factor in It can be a helpful tool If started: Logistics should be discussed with multidisciplinary group Lab, Providers, Hospital Epidemiologist, Infection Prevention, Admin How often? Which sites? Which assay? Cost? Potential end-point for screening should be discussed Hospital Epidemiologist can help facilitate discussion between Lab and Providers to address raised concerns

49 MRSA colonization and risk of infection Among pediatric patients who acquired MRSA colonization in ICU, 47% subsequently developed MRSA infection Colonization pressure is an independent risk factor for hospital-acquired MRSA Extensive published data on risks Calfee DP et al. Infect Control Hosp Epidemiol 2014;35(7) Milstone AM et al. Clin Infect Dis 2011;53:

50 MRSA in the NICU We noted an increase in MRSA infections in the NICU Multidisciplinary meeting: Neonatology MDs and Nurses, Infection Prevention, Microbiology lab, Hospital leadership Decision made to start MRSA screening in NICU Multiple questions arose: How often? How long? What method for screening? Do we do pre-emptive contact isolation?

51 Multiple Actions Staff Education and Communication Active surveillance with weekly nasopharyngeal swabs Initially MRSA Chromagar, eventual move to PCR Pre-emptive contact isolation precautions IC&P staff monitors compliance with hand hygiene and isolation precautions NICU environment has thorough, consistent daily cleaning SUCCESS!! Decreased number of MRSA infections

52 MRSA colonization in NICU MRSA isolates, August 2012 July 2015 NICU I, II, III, IV Nose, NP swab, Nasal Only first specimen

53 MRSA colonization in NICU MRSA isolates of different strains Different antibiotic susceptibility phenotypes PFGE confirmed different isolates Review over time revealed one potentially significant association Increased patient days in the NICU! Data helped support NICU expansion efforts

54 Emerging Infections and Emergency Preparedness

55 Ebola virus disease in the U.S. First patients were medically evacuated August 2: Kent Brantly evacuated from West Africa to Emory in U.S., followed shortly by Nancy Writebol Aug 19: Nancy Writebol discharged Aug 21: Kent Brantly discharged Others medically evacuated: Nick Sacra, Ashoka Mukpo - accessed Craig-Spencer-receives-blood-transfusion-survivor-Nancy-Writebol.html - accessed

56 EVD in the U.S. First case to be diagnosed in U.S. Sept 20: Mr. Thomas Eric Duncan arrives in U.S. from Liberia Sept 24: Felt ill Sept 26: Initially sought medical care Sept 28: Admitted to Dallas Hospital Sept 30: CDC confirms EVD diagnosis Oct 8: Mr. Duncan died First cases of secondary transmission Oct 10: Nurse (Nina Pham) who provided care to index patient developed fever and tested positive for EVD Oct 14: 2 nd nurse (Amber Vinson) who provided care for index patient reported with fever and tested positive for EVD - accessed accessed accessed

57 How do we keep our patients and health care providers safe?

58 GOALS IDENTIFY a patient suspected of having EVD Early recognition is critical CONTAIN the risk of secondary transmission Appropriately isolate a suspected patient PROTECT the patients and health care providers while providing appropriate care Use of proper infection control and prevention precautions

59 Logistics Coordination with Critical Care Medicine, Emergency Medicine, Infectious Diseases, Ambulatory Care Pathology/Laboratory services coordination Ethics committee Environmental services Corporate Communications Waste Management Coordination with Public Health authorities

60 PPE - accessed

61 Diagnostics Safety Concerns Critically important!!! Blood specimens from patients with EVD can be EXTREMELY infectious Labs should not be drawn on patients suspected to have EVD outside of designated area with proper PPE Martines RB, et al. J Pathol E-pub ahead of print Toner, E et al. Disaster Med and Public Health Preparedness 2014;0:1-5 Formenty, P. Ebola Virus Disease, Emerging Infectious Diseases, copyright 2014

62 Ebola portal created

63 Collaboration and Communication Regular multidisciplinary meetings Town hall sessions at various inpatient and outpatient locations Ongoing communication and training System wide drill with mock patient Despite all of this information, the Lab did receive a swab from a clinic with label Rule out Ebola Yikes! Feedback provided. RULE OUT EBOLA

64 Zika virus Culjat M et al. Clinical Infectious Diseases 2016;63(6): Image credit: Ingrid Rabe, Centers for Disease Control and Prevention, COCA Call Jan 26, 2016

65

66 Similar challenge Multidisciplinary meetings Virology lab, Blood bank, OB/Gyn, Pediatrics, Hospital Epidemology, Infection Prevention, Hospital Admin, Corporate communications Primary questions re: screening Blood supply Pregnant women Numerous messages to providers about diagnostic testing as it evolved Providers mandated to complete ALL, Yes, ALL of the required patient information

67 Relationship with Pharmacy AKA We re all in this together

68 Antimicrobial Stewardship Program Excellent model of the synergy between the Microbiology lab, Pharmacy, Provider Close collaboration required to optimize results In addition to our ASP, we have a multidisciplinary Antibiotic Subcommittee Microbiology, ID PharmD, Hospital Epidemiology, Medicine, Surgery, Pediatrics, Transplant Reviews new antimicrobials, vaccines, formulary restrictions Provides recs to P&T Committee to shape policy

69 Case of antimicrobial resistance 45 year old woman with necrotizing pancreatitis complicated by fistulas Had multiple surgeries, indwelling drains and prolonged stays at an outside hospital and LTACH Transferred to our hospital for definitive surgical management. Urine culture obtained on arrival

70 Microbiology lab was concerned

71 Alexander Fleming Moral: If you use penicillin, use enough. Nobel lecture on his discovery of penicillin December 11, accessed Image from

72 - accessed

73 Time to re-think war with microbes Image credit:

74 Joint Commission Effective Jan 2017

75 Four Core Actions 1. Prevent infections to prevent the spread of resistance 2. Tracking: antimicrobial use and resistance 3. Improving antibiotic use and stewardship 4. Developing new drugs and diagnostic tests

76 Days of Therapy Inpatient tracking

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79 Recommended Resource CDC website: Get Smart About Antibiotics Information for patients Free posters, fact sheets Guidelines Patient Education - accessed

80 Batman s approach is NOT recommended Image from

81 Use of Clinical and Professional Guidelines to Improve Use

82 Important ASP issues Appropriate use of antimicrobials is critical Challenging task that requires ongoing monitoring, education, and guidance Clear and consistent messaging to providers is important component Collaboration between Microbiology lab, Pharmacy, Infectious Diseases MD is a must

83 Conclusion Hospital Epidemiologist is an evolving role Collaboration with the Microbiology/Virology lab and Pharmacy is incredibly important Publicly reported measures and resources can be impacted Mutual support allows for optimization of resources and recognition of new needs Health Care is a team sport!!!