Epidemiology practice in Hospitals for students

Dr.A.K .AVASARALA, MD; PROFESSOR & HEAD, DEPT OF COMMUNITY MEDICINE& EPIDEMIOLOGYFATHIMA INSTITUTE OF MEDICAL SCIENCES,KADAPA, AP, INDIAavasarala46@gmail.com

PROMPT• In a hospital meeting, a hospital doctor

asked me“ sir, what epidemiological studies we can ask our students to do in this hospital? .”

• I said “ if you observe every thing with epidemiological view, every function of the hospital can be studied epidemiologically.”

• This conversation prompted me to form this lecture.

LEARNING OBJECTIVES Student should learn the practical skills by conducting

the epidemiological studies at various levels of the hospital

1. Hospital level as a whole

2. Out patients department

3. Inpatients wards

4. Blood bank

5. Diet section

6. Pharmacy

7. Operation theatres

8. Laboratory level

9. Evaluation studies

PERFORMANCE OBJECTIVES

• By learning these studies, the student will be empowered with the skills to help the administrators to improve the quality of the health care delivery at the hospital.

1.Hospital level

Hospital care1. Prepare models for reviewing policies

and procedures for patient care and health care delivery in the hospital catchment areas.

2. Develop written policies to reduce risk-free patient care policies

3. How do you eliminate unnecessary practices?

4. Study the hospital relationship to the external agencies.

 

Outbreak investigation

–How do you plan outbreak investigation in the hospital? ( Take hypothetical example of the neonatal tetanus epidemic in obstetric ward)

Infection control activities

• Find out how the Hospital Infection Committee is working?

• List out the frequently occurring infections in the hospital and chalk out their preventive strategies.

• Similarly find out the deficiencies in central sterilization procedures in the hospital and advise.

Infection control activities.

• Find out the various nosocomial infections in the hospital , their types, sources and suggest preventive measures.

• Prepare the list of infections system-wise, department- wise, ward- wise and form hypotheses and try to test those hypotheses.

Infection control activities

• Prepare in advance the master plans for preventing epidemics of tetanus in the surgical wards and operation theatres and , food poisoning in the diet section.

Bio-wastes disposal• Is there a system for disposing the

liquid and solid wastes of the hospital?

• If yes, how is it working? What are the lapses? How to rectify them?

• Calculate fly index, breeding places index?

• Is the system cost effective? If not suggest alternative?

Cost effective studies• Find out how best to carry out various

functions cost effectively i.e. achieving maximum gains with optimum utilization of resources like men, money, materials, time and skills.

• Calculate the cost effectiveness by means of inputs( capital costs involved, recurring costs, depreciations versus the gains like number of patients treated, lives saved, immunizations done, etc.

• Advise the management how things can be done better and at low cost.

2.Out patient level

Hospital Out- Patient Analysis( OPA)

1.List out ten common causes from the outpatients data?

2.  Prepare ranking list of first ten common causes using PIC code( considering Prevalence, Incidence and Complications of each disease)

 

Morbidity analysis of outpatients

• Select critical variables from the out patient data

• Prepare morbidity tables with different variables• Prepare graphs and diagrams both manually

and using computer• Try to learn visual displays.

•  •  

Morbidity analysis of outpatients

• Try to calculate DALYS for few diseases ( Disability adjusted life years)

• Form various hypotheses from the data available and choose appropriate study design to test each hypothesis stating your reasons for selection of design.

Patient waiting time analysis

• Select a sample of 100 out-patients from various departments by means of stratified sampling and find out the actual waiting time spent by each patent before he/she sees the doctor.

• Find out the mean actual time

• Enquire the patients about the desired waiting time and find out the mean desired waiting time

Patient waiting time analysis

• Find out the reasons for the longer waiting from the patients and the doctors.

• Ask both of them about optimum waiting time.

Patient waiting time analysis

• Plot the actual waiting time, desired waiting time and optimum waiting time on a graph and try to explain and correlate with the reasons given by the doctors and patients.

• Finally correlate with the reasons which you think appropriate.

Referral system studies

– Categorize the patients basing on the place, person referred, type of action taken and feedback sent to the referee.

– Prepare a report on the adequacy, perfect- ness and impact of the referral system.

– Suggest your models for a well worked out referral system. Is it relevant to your national health policy?

Referral system studies

– Choose one of the commonest diseases of your choice.

– Search the records and registers for the addresses of all patents suffering from that disease. Scrutinize the referral documents or registers for particulars.

– Find out where from those patients are referred and who referred them. Search for the referral action taken for the referred patents.

3.In- patients level

Inpatient analysis(IPA)

• Case files(sheets) scrutiny for lapses, appropriateness, completeness and uniformity.

•  

• Select 100 case files, one in every ten cases (10th case sheet). Check and list out the omissions and commissions. List out the corrections.

Inpatient analysis(IPA)

• Find out the relevance of the treatment given using reference text books. For example, find out how many physicians are following WHO DOTS regimens for treating tuberculosis.

• See the prescriptions for the average number of drugs used for treating a disease and the cost effectiveness. Check the misuse, overuse of the drugs

Length of hospital stay studies

• CALCULATE AVERAGE DURATION OF HOSPITAL STAY.

• CALCULATE THE AVARAGE EXPEDITURE FOR THE PATIENT.

• CALCULATE THE DALYS LOST PER EACH HOSPITALIZED PATIENT.

• FIND OUT ALTERNATE STRATEGIES TO REDUCE THE HOSPITAL STAY LIKE HOME MANAGEMENT, PROVIDING FOLLOW UP SERVICES THROUGH PARAMEDICAL STAFF ETC.

Record linkage• :INDIVIDUAL LEVEL:• Gather all the information available with regard to

an individual patient, in the OP sheets, in patient case files, registers and records, death certificates etc.

• link the entire information from an earlier date to till date( In a sequence) and form the summary about patients’ health after scrutinizing the data.

• Make an individual file and store It in a CD. Look for any hypotheses.

•  •  

Record linkage• DISEASE LEVEL:

• For all the top ten ranking diseases, you prepare individual files from the various sources of data available in the hospital by linking the diseases place- wise, time- wise and person- wise.

• Search for the risk factors; link the risk factors and the disease. Formulate hypotheses for testing.

Record linkage• MULTIPLE INTERACTIONS LEVEL:

• Look for a single factor causing several diseases or several factors leading to one disease, several disease occurring at one place or a particular population affected by a particular disease so on.

Emergencies’ management

• How will you manage an emergency situation? (Crisis management)

• Study in detail any case of emergency of your choice in the hospital( road traffic accident, pediatric emergencies and obstetric emergencies)

Emergencies’ management

• Develop a better alternate plan of management hypothetically.

• Repeat this exercise with various emergencies.

• Think about ways to improve your skills of crisis management.

Death certificates scrutiny.

For:

• Uniformity/standardization

• Correctness of the cause of death(underlying condition)

• Calculation of mortality rates,

• Study of mortality trends

• projection of future mortality patterns

 

 

Death certificates scrutiny

• Exercises:

• Check at least 25% of the death certificates for

• Study the most common diseases causing the death.

• Study the mortality patterns and seasonal variations.

Death certificates scrutiny

• Find out • How many certificates are certified as

per WHO international certification of cause of death and how many were in the prescribed format by WHO?

• How many certificates were useful for the national and international comparison?

•  

Mortality rates

• Calculate SMR (Standardized mortality rates) from the IP data and death certificates.

4.Blood bank level

Blood bank studies

• Is there any blood transfusion policy? If yes, is it in accordance with the national policy?

• How the blood samples are collected, stored and utilized?

• Is there any seasonal variation in utilization?

Blood bank studies• Usual screening methods for HIV, Malaria,

ETC.

• The policy for Screening blood for HIV

• Rates of blood borne infections, their seasonal variations,

• Types of donors, percentage of professional donors, reasons for high rates of professional donation than relatives

• Mismatch transfusions, its rates and reasons,

5.Diet section level

Food hygiene • Check how the food is prepared ,stored and

served to the patients.• Find out any scope for occurrence of food

poisoning epidemics.• Examine the food handlers for carrier state of

typhoid, amoebiasis ,giardiasis etc.• Conduct a study on prevalence of carrier state

among the food handlers.• Collect information about previous food borne

outbreaks among the hospital patients.• Prepare the action plans for preventing their

recurrence.

6.Pharmacy level

ABC & VED Analysis• An amount of rupees 25,00000 were

released by the government towards the purchase of medicines for your hospital for one year.

• Discuss in detail how will you plan for the purchase of medicines judiciously using ABC/VED ANALYSIS.

ABC & VED AnalysisFrequency of the usage of drug in the hospital

VitalV

Essential E

Desirable D

A( HIGHLY USED

A V AE AD

B(MODERATELY USED)

B V BE BD

C( LESS USED)

CV CE CD

ABC & VED Analysis

• List out the all the required medicines using the purchase lists of the previous year.

• Classify them as AV, AE, AD, BV, BE, BD, CV, CE, CD groups.

• Find out the cost for each group.

ABC & VED Analysis

• First purchase the groups which are vital,(AV,AE,AD) next essential groups of medicines(BV,BE,BD) . if money is available desirable drugs can be purchased. (CV,CE,CD)

• You can also do this exercise by taking the list of drugs used in the hospital with prices in the past year.

Antibiotic policy

• Find out the rationale of using the antibiotics. If there is a policy, compare with national policy and WHO policy.

• Find out the misuse, overuse of the antibiotics. Find out their rates of misuse.

• Find out the rates of drug reactions in the hospital.

• 7.Operation Theatres level

Surgical diseases• Type of the cases operated most

commonly

• Calculate their rates, seasonal variations

• Prepare System-wise analysis,

• Prepare Surgeon oriented statistics.

• Prepare Patient oriented statistics

Surgical procedures

• Prepare commonest surgical procedures adopted and their cost-effectiveness

• List out their types, preferences with reasons, cost effectiveness.

Complications and mortality studies

• Find out Prevalence rates of intra-operative and post operative complications, their reasons and corrective action

• Calculate Surgical mortality rates, table deaths rates and reasons

8.Laboratory level

Diagnostic test

• FINDOUT THE PROPRIETY OF PRESCRIBING THE TESTS.

• ARE THE DOCTORS PRESCRIBING PROPER DIAGNOSTIC TEST WITH HIGH SENSITIVITY AND SPECIFICITY?

• FIND OUT THE QUANTUM OF UNWANTED TESTS AND ECONOMIC LOSS FOR THE PATIENTS.

STANDARDIZATION • ARE THE LAB PROCEDURES

STANDARDIZED? IF NOT, WHAT ARE THE DEFICIENCIES?

• ARE THE INVESTIGATIONS COST EFFECTIVE?

• OBSERVE SEROSURVEILLANCE FOR DISEASES, COLLECT DATA FOR ACTION.

9.Evaluation studies

Evaluation of services

• Prescriptions and their rationale,• Cost effectiveness of services. • Impact assessment of services by

provider perspectives and user perspectives.

•

Evaluation by Provider perspectives

• Success rates: Calculate average monthly out-patient and inpatient admissions, dept-wise successful treatment rates, nosocomial infection reduction rates , immunization rates, successful surgery rates,

• Failure rates like death rates, surgical failure rates, vaccination failure rates, treatment failure rates, relapse rates etc.

Evaluation by user(client) perspectives

• Treatment satisfaction by the patient

• Cost satisfaction by the patient

• Cultural satisfaction by the patient

• Impact of services on the population rates of the catchment area.

• Services for under- privileged people

• Services for the children and the elderly.

Summary• All aspects of hospital functioning can be

studied by proper application of epidemiological methods.

• As this science provides intelligence( health information) about the hospital population, health action( health promotion, disease prevention) can be taken at all levels in the hospital.

• Hence, Hospital epidemiological surveillance unit is essential in every hospital to improve the hospital services.