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Explain the epidemiologic triad

Epidemiology is the study (scientific, systematic, data-driven) of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (patient is community, individuals viewed collectively), and the application of (since epidemiology is a discipline within public health) this study to the control of health problems. The nature of the field of hospital epidemiology is changing. To maintain a good program, one needs to adapt to the changing environment. This means that hospital epidemiology initiatives need to take into consideration the competing priorities of all stakeholders, internal and external. This skill may determine the success of the program as much as any others in the healthcare complex environment. Hospital epidemiologists use epidemiologic methods not only for surveillance, prevention, and control of nosocomial infections, but also for applying these methods in other areas, including the epidemiology of noninfectious adverse outcomes of medical care.

Aligned to ULO(s)

ULO1: Discuss the primary applications of epidemiology in health care facilities (CLO 1)

ULO2: Explain the epidemiologic triad (CLO 4)

ULO3: Differentiate the three levels of prevention and the situations when the levels of prevention are applicable in a healthcare facility (CLO 1,4)

Many adverse events in healthcare could have been prevented. Epidemiologic principles, used successfully to reduce the risk of nosocomial infections, are also employed to study and manage other adverse outcomes of medical care. Studies of outcomes are also mandated by purchasers and regulators of healthcare, including the Joint Commission and the National Committee for Quality Assurance. Quality outcomes are becoming increasingly transparent.

The measurement of outcomes of medical care had attracted considerable attention in initiatives to reform the U.S. healthcare delivery system. Outcomes assessment provides a method for evaluating and managing the quality and efficiency of healthcare.

In this unit, assume that you are the Manager at Epidemiology Department in a hospital setting.

1. Initial Post: Prepare a report with the items that should be included into the design of a surveillance program for noninfectious adverse outcomes at your facility. Include all these components:
   1. Choose one the following types of noninfectious adverse events at your facility for the surveillance program:
      1. Events related to medication administration, such as wrong drug, wrong dose, drug omitted, drug toxicity, allergic reactions, or idiosyncratic reactions
      2. Events related to procedures, such as noninfectious complications associated with diagnostic or therapeutic procedures
      3. Accidents, such as falls or burns
      4. Event related to new conditions not identified on admission, such as nosocomial deep venous thrombosis, pulmonary emboli, decubitus ulcer, or myocardial infarctions that could not be linked to procedures or medication
      5. Event related to equipment, such as equipment defects, malfunctions, or user-related errors.
   2. After deciding which noninfectious adverse event to include in the surveillance program, prepare a report about specific items to be included in the program.
      1. Be sure to include well-developed, explicit definitions that provide the foundation for consistent measurement across time, place, and other referents (this step will determine, in part, the success of the program). The definitions of the outcomes indicators should be succinct, unambiguous, and constant over time.
      2. To insure validity, use criteria that are validates scientifically and reported in peer-reviewed literature. If you are developing new criteria, then describe the process how consensual validation will be obtained, for example, using the Delphi Technique.
      3. To insure importance, include measurement of the outcomes that are of clinical significance, or can be changed by clinical intervention.
      4. To insure stability, include indicators that can be evaluated over time. If the surveillance program changes criteria and definitions, then the trends cannot be accurately assessed; therefore, criteria should be stable over time. Keep in mind the screening efficiency that includes descriptive characteristic of the criteria, such as sensitivity, specificity, and predictive value.
   3. Describe the process of data gathering.
      1. The data collected and the processes for collecting the data must be consistent across patients or other referents. This objective can be accomplished by using a standardized data collection tool.
      2. The data should be collected in a concise format that will minimize transcribing errors and facilitate easy data entry and analysis.
      3. Avoid two pitfalls when developing a data collection tool: be sure to minimize the entry of free text (recording data as text or statements is labor intensive and increases opportunity for error); and be sure to not expect the data collectors to judge on whether outcome meets the criteria or whether an outcome was iatrogenic (these judgments are subjective and causation is better determined through scientific studies).
      4. Note the sources of the data to be collected, data storage, and retrieval.
   4. Describe the event-specific data.
      1. Keep in mind that the surveillance program must convert event-specific data into rates. For example, the frequency of new conditions or accidents can be reported as cumulative incidence (event of interest for 100 admissions per unit of time [month, year]) or reported as incidence density (event of interest per 1,000 patient-days). Rates of procedure-related adverse events or outcomes can be reported as cumulative incidence and reported as postoperative surgical site infection rates (events/100 procedures/unit of time [month, year]). If physician-specific rates are reported, data should be coded to maintain confidentiality. The rates of medication-related adverse outcomes can be reported as cumulative incidence or incidence density (event of interest/10,000 doses administered/unit time).
   5. Discuss who should receive the surveillance reports, what should be reported, how often the report should be prepared, and resources to support that surveillance program (support staff).
   6. In the concluding paragraph, include two additional long-range objectives of the surveillance program.
      1. How the surveillance indicators will be assessed for validity, sensitivity, specificity, predictive value, consistency of data collection across surveillance staff (reliability)