Experiential learning and mentorship as the foundation of clinical epidemiology training during infectious diseases fellowship: Response to “Training infectious diseases fellows for a new era of hospital epidemiology”

Abstract

A specific, clinical-epidemiology, month-long rotation for all infectious disease fellows as well as a 1-year subspecialty track provides education in clinical epidemiology during infectious disease fellowship training. We describe the educational process created at our institution to provide this training.

Full text

Commentary
Experiential learning and mentorship as the foundation of clinical
epidemiology training during infectious diseases fellowship: Response
to “Training infectious diseases fellows for a new era of hospital
epidemiology”
Shandra R. Day MD , Mohammad Mahdee Sobhanie MD, Nora E. Colburn MD, MPH and Christina Liscynesky MD
Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
Abstract
A specific, clinical-epidemiology, month-long rotation for all infectious disease fellows as well as a 1-year subspecialty track provides education
in clinical epidemiology during infectious disease fellowship training. We describe the educational process created at our institution to provide
this training.
(Received 24 January 2022; accepted 25 February 2022)
Infectious diseases (ID) physicians may have a formal compen-
sated role in hospital infection prevention programs. However,
in the era of COVID-19, all ID physicians have been required to
mitigate infection control issues. We created a specific, clinical-
epidemiology (EPI), month-long rotation for all of our ID fellows
as well as a 1-year subspecialty EPI track for fellows interested in a
career as a Hospital Epidemiologist. The recent commentary by
Martin and Snyder1outlined an educational framework supported
by the Accreditation Council for Graduate Medical Education
(ACGME) and the Society for Healthcare Epidemiologists of
America (SHEA). Here, we have outlined the educational process
that began in 2019–2020 academic year at The Ohio State
University Wexner Medical Center (OSUWMC). Education stems
from excellent teaching and real-world experience. Our institution
has a robust EPI department, consisting of an administrative direc-
tor, 4 medical directors, seventeen infection preventionists (IPs)
including 3 senior IPs, 5 high-level disinfection (HLD) analysts,
a data manager, and a program coordinator. The medical directors
have focused oversight of the various patient populations, and they
work closely with the IPs assigned to those locations.
As an overview, OSUWMC is a large, academic, quaternary-
care, integrated health system comprising 1,600 beds (including
210 ICU beds and 204 PCU beds). The system includes
University Hospital (a level I trauma and burn center, liver and
kidney transplantation programs, labor and delivery with an adja-
cent 49 bed level III neonatal intensive care unit managed by
Nationwide Children’s Hospital), the James Cancer Hospital
(the Comprehensive Cancer Center Hospital with a bone marrow
transplant unit), Ross Heart Hospital (with cardiology, cardiac and
vascular surgery, and heart and lung transplantation programs),
Brain and Spine Hospital (for neurology and neurosurgery),
Dodd Rehabilitation Hospital, Harding Hall (an inpatient psychi-
atric unit), Talbot Hall (an inpatient addiction treatment unit),
East Hospital (a community-based hospital with orthopedic sur-
gery), and ∼200 primary, specialty, and subspecialty clinics includ-
ing 4 ambulatory surgery centers.
Clinical epidemiology training during infectious diseases
fellowship
Epidemiology rotation
The EPI rotation is a required 1-month-long rotation during the
second year of ID fellowship. Fellows attend weekly hospital
acquired infection (HAI) surveillance meetings, and Infection
Prevention Committee (IPC) meetings. They learn one-on-one
with IPs, and they are required to present an article for monthly
journal club and successfully complete a quality improvement
project (Table 1). Completed projects include evaluation of
Clostridioides difficile (CDI) testing, a clinical review of candidemia
cases, and a clinical review of carbapenem-resistant Enterobacterales
colonization in solid-organ transplant patients.
Epidemiology track
The EPI track was developed for second-year fellows interested in
pursuing a career in hospital epidemiology with the goal of expos-
ing and teaching the fellow the knowledge and skills necessary to be
both a successful leader and expert in infection prevention. This
program not only entails learning about specific HAI definitions
as determined by the CDC but also how to effectively interact with
Author for correspondence: Shandra R. Day, MD, 410 W 10th Ave, N 1143 Doan Hall,
Columbus, OH 43210. E-mail: shandra.day@osumc.edu
Cite this article: Day SR, et al. (2022). Experiential learning and mentorship as the
foundation of clinical epidemiology training during infectious diseases fellowship:
Response to “Training infectious diseases fellows for a new era of hospital epidemiology”.
Antimicrobial Stewardship & Healthcare Epidemiology,https://doi.org/10.1017/ash.2022.38
© The Author(s), 2022. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America. This is an Open Access article, distributed under the
terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original
article is properly cited.
Antimicrobial Stewardship & Healthcare Epidemiology (2022), 2, e59, 1–4
doi:10.1017/ash.2022.38
https://doi.org/10.1017/ash.2022.38 Published online by Cambridge University Press

Table 1. Epidemiology Fellow Rotation and Track Curriculum
Specific Activity Rotation Track
System meetings
Weekly surveillance XX
Monthly IPC meeting XX
Staff meeting X
Task force meetings including CLABSI, CAUTI, and CDI XX
Waterborne pathogen workgroup X
Emerging and infectious pathogens workgroup XX
Individual meetings with IPs
Department overview and scope XX
Construction/Facilities XX
Water management and air quality XX
Surveillance and process measure prevention: CAUTI, CLABSI, VAP, and SSI X X
Unit rounds XX
HLD and sterilization XX
Ambulatory infection prevention XX
High-risk areas—BMT, HD, endoscopy, etc XX
Influenza and TB plan XX
Cluster & outbreak investigation/exposures XX
Micro reports and CDI/MDRO pathogens XX
OSUWMC policy review
COVID-19 resources/policies XX
Hand hygiene policy XX
Bloodborne pathogen exposure control policy X
Cleaning and low-level disinfection policy X
Employee health services infection prevention policy X
Infection prevention plan XX
Isolation policy X
TB control plan X
Ambulatory infection prevention plan X
Aseptic technique policy X
HLD X
HD infection prevention policy X
Required reading
CDC COVID-19 infection control guidance for healthcare professionals5X
CDI guidelines6XX
Compendium of strategies to prevent healthcare-associated infections in acute care hospitals7XX
Guidance for infection prevention and healthcare epidemiology programs: healthcare epidemiologist skills and competencies8XX
Guideline for hand hygiene in healthcare settings9XX
Duration of contact precautions for acute care settings10 XX
SHEA expert guidance: Outbreak response and incident management11 XX
Review NHSN definitions12 X
Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings13 X
Required coursework
Primer on Healthcare Epidemiology, Infection Control and Antimicrobial Stewardship: Online ID Fellows Course4XX
SHEA/CDC training certificate course in healthcare epidemiology X
Present EPI journal club XX
(Continued)
2 Shandra R. Day et al
https://doi.org/10.1017/ash.2022.38 Published online by Cambridge University Press

administrators, physicians, facilities personnel, clinical staff, and
public health officials while building their expertise in systems-
based practice. The fellow learns how to construct health system–
wide protocols, to determine and respond to exposures of infec-
tious agents, to investigate new products related to infection pre-
vention. They learn about facility systems (ie, water and airflow
management), and they implement quality improvement projects.
Because OSUWMC is a quaternary-care, integrated health system,
the fellow learns the different requirements needed to ensure a safe
environment for these unique populations such as bone marrow
and solid-organ transplant patients, patients with acute leukemia,
dialysis, patients in congregate settings, etc.
The EPI fellow has the opportunity to work alongside the entire
EPI team during any hospital outbreak that occurs during the year
regardless of what rotation they are on (Table 1). The fellow
attends meetings with hospital administration and key stakehold-
ers related to the outbreak, performs background research. Each
fellow is responsible for helping with the outbreak interventions
and timeline construction as well as any academic abstracts and/
or manuscripts. Thus far, 2 fellows have successfully completed
the track, and both actively participated in major outbreak inves-
tigations.2,3The COVID-19 pandemic provided the unique oppor-
tunity for the medical directors to include the fellow in senior
leadership and command center meetings as well as smaller multi-
disciplinary workgroup discussions and decision making.
Finally, this yearlong track allows the development of a long-
term mentoring relationship between the fellow and the medical
directors. While one medical director takes the lead on organizing
the track, the fellow is actively mentored by all 4 faculty. This
arrangement allows the fellow to observe various leadership styles
and to learn the importance of collaboration and teamwork in
systems-based practice.
Core competencies and activities
Surveillance and reporting
The Clinical Epidemiology Department meets weekly for 2 hours
to review HAI surveillance. Cases of possible ventilator associated
pneumonia (PVAP), central-line–associated bloodstream infec-
tion (CLABSI), catheter-associated urinary tract infection
(CAUTI), and surgical site infection (SSI) are presented to the
medical directors. Opportunities for HAI reduction are identified
and discussed. HAI data are shared as close to real time as possible,
with a formal monthly report to leadership and at the IPC. The
enterprise-wide IPC has been established, and 5 other committees
focus on specialized populations. Rotation fellows participate in
weekly surveillance meetings to understand how surveillance is
conducted, including multidisciplinary discussions and internal
and external reporting, and to understand the differences between
clinical and surveillance definitions. Fellows also meet individually
with the IPs to review NHSN definitions, HAI process measure
prevention, and required reporting to state and local health depart-
ments. The fellow is expected to attend at least 1 meeting of the
system-wide HAI reduction task force to obtain a deeper under-
standing of the data and reporting including external benchmark-
ing using SIR data. They are also expected to discuss strategies for
HAI reduction. In addition, the EPI track fellow attends weekly
surveillance meetings when they are not assigned to inpatient
consultation. This exposure provides them with an in depth under-
standing of NHSN definitions and how to identify and communi-
cate HAI reduction opportunities. Fellows also meet with IPs and
the data manager to understand the reporting software advantages
and limitations and HAI validation methods. They regularly attend
CLASBI, CAUTI, and CDI HAI reduction task-force meetings,
where they learn HAI reduction strategies in the context of other
patient safety events and help to identify high-risk patient popu-
lations. In addition to participation in the HAI task-force meetings,
they attend the OSUWMC IPC, individual hospital infection pre-
vention work groups and other system-wide quality meetings that
are deemed relevant by the medical directors.
Cluster detection, investigation, and resolution
Fellows are required to complete the Primer on Healthcare
Epidemiology, Infection Control and Antimicrobial Stewardship:
Online ID Fellows Course by the SHEA4at the beginning of their
rotation, which provides an excellent background for cluster and
outbreak investigations. Fellows meet with the IPs individually
to discuss the exposure notification process for significant patho-
gens including tuberculosis, varicella, scabies, and SARS-CoV-2.
Active participation in cluster detection, outbreak investigation,
and subsequent follow-up is a strength of the EPI track. Both fel-
lows who completed the EPI track participated in a significant clus-
ter investigation. Our 2019–2020 fellow investigated a cluster of
postpartum group A Streptococcus infections on the labor and
delivery unit2and our 2020–2021 fellow investigated a cluster of
COVID-19 on an inpatient hospital unit involving multiple modes
of transmission.3Through these investigations, the fellows learned
the role of case–control and cohort investigation and how to con-
duct an exposure investigation. Following both of these investiga-
tions, each fellow has had the opportunity to present their
respective investigation, findings, and interventions to various
institutional stakeholders and leaders and at national meetings.
Pathogen transmission and transmission interruption
The competencies outlined by Martin and Snyder1are addressed
during both the EPI rotation and track. Hand hygiene, modes of
pathogen transmission, and rationale for isolation are taught
Table 1. (Continu ed )
Specific Activity Rotation Track
Academic project
Quality improvement project XX
Abstract/Manuscript submission X
Note. IPC, infection prevention and control; CLABSI, central-line–associated bloodstream infection; CAUTI, catheter-associated urinary tract infection; CDI, Clostridioides difficile infection; VAP,
ventilator-associated pneumonia; SSI, surgical-site infection; HLD, high-level disinfection; BMT, bone marrow transplantation; HD, hemodialysis; TB, tuberculosis; MDRO, multidrug-resistant
organism; NHSN, National Health Safety Network; SHEA, Society for Healthcare Epidemiologists of America; CDC, Centers for Disease Control and Prevention; EPI, clinical epidemiology.
Antimicrobial Stewardship & Healthcare Epidemiology 3
https://doi.org/10.1017/ash.2022.38 Published online by Cambridge University Press

starting in the first year of fellowship and are reinforced during the
SHEA training course. These aspects are further reinforced during
the rotation and track activities when meeting and performing
rounds with the IPs and when reviewing the OSUWMC isolation
and hand hygiene policy. General HAI reduction strategies are
reviewed in the SHEA compendium, and institutional strategies
are discussed during individual meetings with the IPs, during
HAI task-force meetings and the IPC. In addition, fellows join
the IPs during unit rounding where hand hygiene, personal protec-
tive equipment, and isolation practices are observed in real time.
Fellows on the EPI track review OSUWMC cleaning and low-level
disinfection policy, the high-level disinfection policy and round
with the IPs and HLD analysts in areas performing high- and
low-level disinfection.
Additional competencies
Many of the additional competencies outlined by Martin and
Snyder1are included as part of the program activities (Table 1)
including environment of care, occupational health and emergency
preparedness. The EPI department maintains a close working rela-
tionship with the clinical microbiology and antimicrobial steward-
ship departments, and fellows participate in meetings and projects
involving these departments in addition to dedicated training in
these departments as part of their fellowship training.
Academics and scholarly activities
All of the fellows are required to present their quality research
project at both the enterprise-wide IPC and the ID conference
series. Depending on the topic, they may present at other sessions,
including grand rounds, the Central Ohio APIC chapter meetings,
and the SHEA and IDSA conferences.
Once the EPI track is completed, the fellow receives a graduate
medical education (GME) certificate recognizing the successful
completion of the subspecialty training. This certification is valu-
able for future employment opportunities and provides recogni-
tion that can be understood by administrators.
Discussion
Here, we describe our institution’s EPI ID fellow education using
both a 1-month rotation and 1-year training track. In review of the
model outlined by Martin and Snyder,1our program includes
many of these core competencies with a focus on experiential
learning. Our program’s strengths include strong training in sur-
veillance and reporting, close collaboration with the IPs, dedicated
mentoring by the medical director faculty, and real-time cluster
and outbreak investigations. All fellows participate in a quality
improvement project, but additional training on the principles
of quality improvement and project design would be beneficial
as well as additional experience in program implementation. A
future consideration would be utilizing a postgraduation survey
to identify additional opportunities for program improvement.
Providing EPI training during ID fellowship is critical, especially
given the heightened awareness of infection prevention due to
the COVID-19 pandemic. The 2 fellows who have completed
the track are working in clinical epidemiology roles at major aca-
demic centers. Our program has been successful in providing this
training to all fellows and more comprehensive training for fellows
interested in pursuing a career in healthcare epidemiology.
Acknowledgments.
Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this
article.
References
1. Martin E, Snyder G. Training infectious diseases fellows for a new era of
hospital epidemiology. AntimicrobSteward Healthcare Epidemiol 2021;1:E25.
2. Witherspoon K, Haden M, Smyer J, et al. A cluster of COVID-19 on an
inpatient hospital unit involving multiple modes of transmission. Antimicrob
Steward Healthcare Epidemiol 2021;1:S2–S3.
3. Haden M, Liscynesky C, Colburn N, et al. Clusters of postpartum group A
Streptococcus (GAS) infections on a labor and delivery (L&D) unit June–
October 2019. Open Forum Infect Dis 2020;7:S474–S475.
4. Primer on healthcare epidemiology, infection control and antimicrobial
stewardship. SHEA Online Education Center website. https://learningce.
shea-online.org/content/primer-healthcare-epidemiology-infection-control-
antimicrobial-stewardship. Published 2019. Accessed January 2022.
5. Interim infection prevention and control recommendations for healthcare
personnel during the coronavirus disease 2019 (COVID-19) pandemic.
Centers for Disease Control and Prevention website. https://www.cdc.gov/
coronavirus/2019-ncov/hcp/infection-control.html. Published September
10, 2021. Accessed January 2022.
6. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for
Clostridium difficile infection in adults and children: 2017 update by the
Infectious Diseases Society of America (IDSA) and Society for Healthcare
Epidemiologists of America (SHEA). Clin Infect Dis 2018;66:e1–e48.
7. Yokoe DS, Anderson DJ, Berenholtz SM, et al. A compendium of strategies
to prevent healthcare-associated infections in acute care hospitals: 2014
updates. Infect Control Hosp Epidemiol 2014;35:967–977.
8. Kay DS, Anderson DJ, Cook E, et al. Guidance for infection prevention and
healthcare epidemiology programs: healthcare epidemiologist skills and
competencies. Infect Control Hosp Epidemiol 2015;36:369–380.
9. Boyce JM, Pittet D. Guidelines for hand hygiene in healthcare settings.
MMWR Recomm Rep 2002;51:1–45.
10. Banach DB, Bearman G, Barnden M, et al. Duration of contact precautions
for acute-care settings. Infect Control Hosp Epidemiol 2018;39:127–144.
11. Banach DB, Johnston BL, Al-Zubeidi D, et al. Outbreak response and inci-
dent management: SHEA guidance and resources for healthcare epidemi-
ologists in United States acute-care hospitals. Infect Control Hosp
Epidemiol 2017;38:1393–1419.
12. National Healthcare Safety Network (NHSN). Patient Safety Component
Manual. Centers for Disease Control and Prevention website. https://www.
cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.AccessedJanuary
2022.
13. Siegel JD, Rhinehard E, Jackson M, et al. 2007 Guidelines for isolation pre-
cautions: preventing transmission of infectious agents in healthcare settings.
Am J Infect Control 2007;35:S65–S164.
4 Shandra R. Day et al
https://doi.org/10.1017/ash.2022.38 Published online by Cambridge University Press