for surveillance of nosocomial infections and control measures.4 After ... disease physicians to become involved in an increasingly important patient- care review ...
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THE ROLE OF INFECTIOUS DISEASE PHYSICIANS IN HOSPITAL INFECTION CONTROL* ROBERT W. HALEY, M.D. Department of Internal Medicine University of Texas Health Science Center Dallas, Texas
INFECTION control programs have become a standard practice in hospital care. 1-3 Between 1970 and 1980 virtually all American hospitals created positions for infection control practitioners and started organized programs for surveillance of nosocomial infections and control measures.4 After several studies in individual hospitals found significant reductions in nosocomial infection cases following the establishment of an infection control program,5-8 the Centers for Disease Control conducted a nationwide controlled evaluation study that found a 32% reduction in infection rates attributable to specific surveillance and control components.9 Subsequent prospective interventions in individual hospitals have corroborated the finding; 10-12 a cost-benefit analysis has demonstrated the financial incentive for hospitals to adopt such programs;'3 and a recent American Hospital Association publication outlined a practical management strategy for rapidly instituting the approach. 14 Recent nationwide surveys indicate, however, that relatively few hospitals have yet established programs incorporating all of the components found effective.'5 Because of the need for clinical infectious disease insights in the direction of these programs, infection control offers an opportunity for infectious disease physicians to become involved in an increasingly important patientcare review function of the hospital. For them to be successful, however, they must become familiar with the rationales and techniques of infection control programs and overcome several potentially serious obstacles. *Presented as part of the Fourth Annual SK & F/FSK Anti-Infective Conference, Controversies in Diagnosis and Management of Infectious Disease, held by the Division of Infectious Diseases/ Epidemiology of the College of Physicians and Surgeons of Columbia University and funded by a grant from Smith-Kline French Laboratories/Fujisawasa Smith-Kline at Orlando, Florida, September 7-9, 1986. Address for reprint requests: UTHSCD, Division of Epidemiology E5.711, 5323 Harry Hines Blvd., Dallas TX 75234
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THE JOB OF INFECTION CONTROL PHYSICIAN In the early developmental phase of infection control programs in the 1960s, most published models recommended that a physician, called the infection control officer, should head the program and perform most of the surveillance and control. With the successful demonstration that specially trained nurses could perform most of the required work, the role of the physician became less clear. Subsequently, infection control programs evolved in two directions. In most hospitals a physician without special interest or training was named chairman of the infection control committee on the regular rotating committee assignment system.'6 Alternatively, particularly in teaching hospitals, a physician, most often a pathologist, sought special training in infection control and actually assumed the daily management of the program, including direct supervision of the infection control nurse.'6 In some cities, physicians with particular interest in infection control have organized consulting services in infection control that they offer to several hospitals. '7 According to repeated national surveys, only 60% of American hospitals have a physician with special interest or knowledge in infection control as the infection control physician. 16 Because of their widely variable commitments to infection control, their infection control titles are diverse. Those deeply involved in hands-on management of the program tend to use the title hospital epidemiologist, whereas those with peripheral involvement are most often called simply chairman of the infection control committee. Other titles include infection control officer and infection control consultant. Some hospitals with highly developed infection control programs have a full-time hospital epidemiologist in addition to the rotating position of committee
chairman. The need for special interest in and knowledge of infection control techniques is that the modem approach to infection control has evolved a specialized knowledge base and set of skills (e.g., epidemiologic reasoning, surveillance technology, statistical analysis, computer skills) generally not learned in medical school, residency, or fellowship training and are largely foreign to most physicians. According to the findings of the SENIC Project, the characteristic of the infection control physician most essential for reducing nosocomial infection rates is that he has taken a special training course in infection control.9 Although the job description of the infection control physician is usually not written, a management error that should be corrected in the future, there Bull. N.Y. Acad. Med.
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are six main functions in the most recent framework of program organization. 4 The first three, which deal with surveillance and focused feedback, are the most critical but presently the least likely to be included. Develop objectives for surveillance. The most important function is to lead the infection control committee to formulate specific outcome objectives for the surveillance system. This is crucial because unfocused routine surveillance systems seldom reduce infection risks. For surveillance to have an impact, specific objectives must be conceived ahead of time and a discrete surveillance system developed to address each objective. 14 Once this objectives-oriented approach is adopted, clinical infectious disease insights must be incorporated into the process of formulating the objectives so that the focused feedback will be clinically relevent. Design clinically relevent surveillance reports. When surveillance data are collected and analyzed and potential infection problems identified, the infection control physician must provide clinical perspectives in the design of the surveillance reports. Since the purpose of the reports is to give clinicians a new insight into an infection problem affecting their patients, the report must be analyzed and presented in a way that effectively anticipates their questions and shows clinical insights. This requires a physician's attention in the design of the reports. Interpret surveillance reports to physicians. Experience has shown that documenting a nosocomial infection problem in a clinically insightful report is not always sufficient to influence clinicians to alter patient-care practices that predispose to the problem. Often the report must be delivered by a respected colleague who understands the analysis, can defend the epidemiologic process, and will personally support the conclusions. Investigate outbreaks. The infection control physician must be adept at epidemiologic approaches to infection outbreaks, because when one occurs it is often a highly visible emergency in which the clinical staff and administration alike expect rapid and decisive action. Since outbreak investigation was one of the main stimuli behind the early infection control programs in the 1960s, this function has long been a widely recognized responsibility. Although the expertise must be available, outbreak investigation must not overshadow the more important surveillance and reporting functions oriented toward long-term objectives to prevent endemic infections, because only 2 % of nosocomial infections occur in outbreaks.'8 Lead the infection control committee in formulating policies. In most hospitals the authority for setting policy for infection control is delegated to the Vol. 63, No. 6, July-August 1987
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infection control committee by the hospital's administration. At virtually every committee meeting a host of issues require decisions. Even though many of these decisions may have no direct impact on the hospital's infection rate, prudent and cost-effective decisions reflecting a broad knowledge of hospital medicine as well as infection control must be made. In most hospitals the infection control physician presides over the committee and is expected to guide the policy-making process wisely. Collaboration with the infection control practitioner. In most hospitals where the infection control physician's position is filled on a two-year rotating basis, the infection control practitioner is the one with the most knowledge and experience in infection control. In this situation, the physician collaborates with and supports the work of the practitioner, but does not actually supervise him. In hospitals where the infection control physician's position is held by a specially trained epidemiologist, he may be the practitioner's supervisor. Regardless of which supervisory arrangement is used, a close professional collaboration between the infection control physician and the infection control practitioner is an essential ingredient of the successful infection control program. INVOLVEMENT OF INFECTIOUS DISEASE PHYSICIANS
National surveys of infection control programs in American hospitals documented the involvement of infectious disease physicians in 1975 and again in 1983.15,16 In the 1975 survey all American hospitals were sent a questionnaire, and 81 % responded; in 1983 a stratified random sample composed of 449 hospitals was surveyed, and 96% responded. The responses in the 1983 survey were weighted by sampling weights reflecting the stratified random sampling process to produce valid estimates of the target universe of American hospitals comparable to the 1975 survey. In 1983 infectious disease physicians served as the infection control physicians in only 11 % of American hospitals, up from 9% in 1975 (Table I). Whereas they held such positions in only 5 % of non-teaching hospitals in both years, by 1983 they had assumed this role in almost half of teaching hospitals (i.e., those affiliated with a medical school). The percentage of hospitals in which the position of infection control physician received special financial remuneration for infection control services approximately doubled in the period studied (see table). By 1983 more than half of infectious disease physicians in these positions were paid for infection control services, whereas few physicians of other specialties were paid. Bull. N.Y. Acad. Med.
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RECENT TRENDS IN INFECTIOUS DISEASE PHYSICIANS' ROLE IN HOSPITAL INFECTION CONTROL
1975
1983
35 5 9
45 5 11
Percentage of infection control physicians who receive pay for infection control work Infectious disease physicians Physicians of other specialties All infection control physicians
25 6 9
53 9 17
Percentage of infection control physicians with a training course in infection control Infectious disease physicians Physicians of other specialities All infection control physicians
44 25 28
35 23 25
Percentage of U.S. hospitals with an infectious disease physician serving as the infection control physician In teaching hospitals In non-teaching hospitals In all U.S. hospitals
Few gains were made, however, in the critical need for special training of infection control physicians, only a quarter having taken any type of training course in infection control (Table I). Infectious disease physicians in these positions were somewhat more likely to have had training than physicians of other specialties, but the percentage with training actually decreased in both groups. These findings indicate that infectious disease physicians are beginning to dominate the position of infection control physician in teaching hospitals but are not significantly involved in non-teaching hospitals. Whereas they are increasingly paid for their infection control services, they are not being adequately trained to perform the job.
FUTURE OBSTACLES
The most important obstacle to infectious disease physicians' taking a larger role in the nation's infection control programs is the lack of pay for infection control work. Although teaching hospitals increasingly recognize the financial necessity to pay for sound medical input into infection control, non-teaching hospitals have not, and the latter comprise the vast majority Vol. 63, No. 6, July-August 1987
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of American hospitals. The validation of the role of the infection control physician by the SENIC Project, along with changes in regulatory pressures and awareness of the financial incentives to reduce costly complications,2'3,13-"5 should make hospital administrators increasingly amenable for quality medical direction of infection control. Once the financial incentives are in place, the next greatest obstacle is the lack of training of infectious disease physicians and those of other specialties in the techniques of infection control. With surveillance, epidemiologic analysis, and feedback of focused results to clinicians becoming a central focus, few physicians are prepared to take a leading role, and in many instances they appear to impede the progress of a trained infection control practitioner. To address this deficiency would require the addition of infection control training, including epidemiologic skills and experience in statistical analysis of surveillance data, to infectious disease fellowships and postgraduate seminars. Presently, opportunities for such training are quite limited. The continued lack of training will seriously limit involvement of infectious disease physicians in infection control. A final obstacle is the infectious disease physician's potential conflict of interest between infection control duties and private practice income. In some circumstances, the infection control physician must take unpopular action to investigate or to control an infection problem, e.g., suspend elective surgery, close a ward to admissions, set up a computer system to calculate surgeon-specific or procedure-specific wound infection rates. If other physicians disagree with such measures, they might elect not to seek future consultations from the infectious disease physician. This conflict is best minimized by careful design of surveillance systems and control measures and by thorough education of the hospital's medical staff before specific problems arise. CONCLUSION
The field of infection control is currently at a critical crossroads. Although a scientific basis has been established,5'2 relatively few hospitals' infection control programs have adopted the constellation of surveillance, control, and personnel components shown to be efficacious and cost-effective.'3"4 With the recent elevation of infection control to a full condition for reimbursement in the Medicare-Medicaid regulations, which require a system to fdentify and handle infection risks, and the imminent revision of the guidelines of the Joint Commission on Accreditation of Hospitals along similar lines, Bull. N.Y. Acad. Med.
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there will soon be increased pressure for infection control programs to become more effective. Knowledge and leadership from those who hold the position of infection control physician will be essential for this critical transition. These trends suggest a great opportunity for infectious disease physicians to become more widely involved in infection control, thus providing them a new avenue for professional service and income. Further trends suggest that hospitals are willing to pay for qualified medical experts to lead their new cost-effective infection control programs. Unless a serious void in training is filled, however, many infectious disease physicians will not be qualified to fill these positions. ACKNOWLEDGEMENT The author acknowledges the assistance of John W. White, Ph.D., of the Centers for Disease Control in statistical computing. REFERENCES 1. Guidelines for the Prevention and Control of Nosocomial Infections. Atlanta, Centers for Disease Control, 1981. 2. Infection Control. Accreditation Manual for Hospitals. Chicago, Joint Commission on Accreditation of Hospitals, 1976. 3. Health Care Financing Administration: Infection control. Medicare and Medicaid programs; conditions of participation by hospitals; final regulations, effective September 15, 1986. Fed. Reg. June 17, 1986, pp. 22010-048. 4. Haley, R.W. and Shachtman, H.R.: The emergence of infection surveillance and control programs in U.S. hospitals: An assessment, 1976. Am. J. Epidemiol. 111:574-91, 1980. 5. Brewer, G.E.: Studies in aseptic technic, with a report of some recent observations at the Roosevelt Hospital. J.A.M.A. 64:1369-72, 1915. 6. Cruse, P.J.E. and Foord, R.: A fiveyear prospective study of 23,649 surgical wounds. Arch. Surg. 107:206-10, 1973. 7. Cruse, P.J.E. and Foord, R.: The epidemiology of wound infection: a 10year prospective study of 62,939 Vol. 63, No. 6, July-August 1987
wounds. Surg. Clin. North Am. 60:2740, 1980. 8. Shoji, K.T., Axnick, K., and Rytel, M.W.: Infections and antibiotic use in a large municipal hospital 1970-1972: A prospective analysis of the effectiveness of a continuous surveillance program. Health Lab. Sci. 11:283-92, 1974. 9. Haley, R.W., Culver, D.H., White, J.W., et al.: The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am. J. Epidemiol. 121:183205, 1985. 10. Condon, R.E., Schulte, W.J., Malagoni, M.A., and Anderson-Teschendorf, M.J.: Effectiveness of a surgical wound surveillance program. Arch. Surg. 118:30307, 1983. 11. Olson, M., O'Conner, M., and Schwartz, M.L.: Surgical wound infections: A 5-year prospective study of 20,193 wounds at the Minneapolis V.A. Medical Center. Ann. Surg. 199:253-59, 1984. 12. Borst, M., Collier, C., and Miller, D.: Operating room surveillance: A new approach in reducing hip and knee
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prosthetic wound infections. Am. J. Infect. Control 14:161-66, 1986. 13. Haley, R.W., White, J.W., Culver, D.H., and Hughes, J.M.: The financial incentive for hospitals to prevent nosocomial infections under the Prospective Payment System: An empirical determination from a nationally representative sample. Manuscript submitted. 14. Haley, R.W.: Managing Hospital Infection Control for Cost-Effectiveness. Chicago, Am. Hosp. Assoc. 1986. 15. Haley, R.W., Morgan, W.M., Culver, D.H., et al.: Hospital infection control: Recent progress and opportunities under
prospective payment. Am. J. Infect. Control 13:97-108, 1985. 16. Haley, R.W.: The "hospital epidemiologist" in U.S. hospitals, 1976-1977: A description of the head of the infection surveillance and control program. IC Infect. Control 1:21-32, 1980. 17. Ehrenkranz, N.J.: Observations on the consortium method of infection control. Infect. Control 7:395-96, 1986. 18. Haley, R.W., Tenney, J.H., Lindsey, J.O., et al.: How frequent are outbreaks of nosocomial infection in community hospitals? Infect. Control 6:233-36, 1985.
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