Infection Control Q&A

New HIP director aims to expand CDC mission

(Editor’s note: Julie Gerberding, MD, MPH, recently was named the new director of the hospital infections program at the Centers for Disease Control and Prevention. She formerly was the director of HIV testing and counseling services at San Francisco General Hospital and an associate professor of medicine at the University of California-San Francisco. In addition, Gerberding is a frequent faculty member at medical conferences and has published numerous articles on a variety of infection control and health care epidemiology issues. During a recent interview with Hospital Infection Control, she outlined some of her initial priorities at the CDC and assessed the changing nature of health care delivery.)

Q: What are some of your initial priorities for action at the CDC Hospital Infections Program (HIP)?

A: "I think the biggest immediate priority is to expand the focus and scope of HIP’s activities to venues other than acute care hospital settings. We have made some inroads into that already, but we need to really develop a consistent program that addresses the surveillance, response, research, and prevention needs in these other areas."

Q: Would that include broadening the mission of the CDC Hospital Infection Control Practices Advisory Committee (HICPAC), which has focused primarily on acute care hospitals?

A: "Absolutely. HICPAC has a very important role to play as the advisors to HIP. To the extent that their focus is on the health care delivery system and not just acute care hospitals, it makes it even more feasible for us to move in that direction as well. One of the hidden agendas’ under this topic is building constituency and partnerships, because right now we certainly don’t have the resources to build this program overnight. We have to initiate careful attention to this."

Q: Would this effort ultimately include additional infection control guidelines for other settings such as long-term care and home health?

A: "The first thing we need to do is measure the problem. We need to establish surveillance systems so that we can understand how big the problem is and what should be the focus of intervention. I think we are already receiving clear messages from constituents that there is a need for surveillance definitions and guidelines for these other venues. APIC, SHEA, and HIP are working together to get the ball rolling on this."

Q: How are health care delivery changes affecting the traditional relationships between public health and health care facilities?

A: "We are in an era of blurring boundaries. There used to a very thick wall between the acute care hospital, the outpatient setting, and the home. Those boundaries are so blurred now that it really makes much more sense to think about populations of patients — not so much where they are right now, but where they are in the overall spectrum of care delivery systems. Where have they been and where are they going next? When you start looking at the time continuum of risk factors for infection, you really do have to look at that in the context of a population. It is that movement from patient to population that makes this so much more like public health. Because we are really thinking about populations of people who are in flux, in [various] states of wellness and illness as they move in and out of the care delivery system. It is much more dynamic than the old static models, and much closer allied with the traditional public health [emphasis] on population-based surveillance and intervention. That makes it real exciting. Personally, I see as one of my [goals] here trying to improve linkages with health departments and the care delivery system, because we have much more in common now than we did before."

Q: Some have noted that health care systems with high-quality infection control programs will be more competitive under managed care, but there also are concerns about disclosing nosocomial infection rates — particularly if they are used to market health care systems.

A: "This is not unique to infection rates. This is probably apparent in any outcomes measurement in a facility. Unless you have confidence that you can stratify the outcome for hidden variables that affect it, such as severity of patient illness, etc., making direct comparisons is dangerous, inaccurate, and shouldn’t be done. So yes, there is concern about reporting specific rates used for interfacility comparison. HIP is taking on the challenge of trying to learn what are the most important criteria to stratify risks to improve the quality of interfacility comparisons. We still do everything we can to protect the confidentiality of the institutions that contribute to our surveillance systems."

Q: Will you pursue any new CDC guidelines or recommendations based on your clinical research in such areas as blood exposures and glove use in the operating room? For example, you have emphasized in the past that it is time for routine double-gloving in the OR.

A: "Speaking for myself, I think that double gloving should be a standard practice unless there is a contraindication. To take my personal opinion and move it into the policy department would depend on expert input from people on the front lines — not just epidemiologists, but people who are really in that field. My sense is, on that particular topic, that there is growing momentum among surgeons and surgical care providers that [double gloving] is actually a good idea and it is becoming a more common practice."