ABSTRACT OF THE DISSERTATION
The Hospital as Environment: Assessing and Improving the Efficacy and Impacts of Interventions Designed to Reduce Hospital Acquired Infections
Evelyn Natalia Alvarez
Doctor of Philosophy in Environmental Health Sciences
University of California, Los Angeles, 2018
Professor Hilary Godwin, Co-Chair
Richard J. Jackson, Co-Chair
The overarching goal of the work described herein is to examine strategies for improving the safety of hospital environments. Specifically, I examine the evidence-base used to approve antimicrobials that could be linked to health outcomes, consider the cost-effectiveness of emerging infection prevention technologies, such as antimicrobial copper surfaces, and assess the psychosocial impacts of pediatric isolation precautions. There has been considerable interest in evaluating the in vitro antimicrobial efficacy of copper alloy surfaces as demonstrated by the numerous in vitro studies conducted in the past decade, prompting us to consider the clinical efficacy of such emerging technologies. The first section provides a critical review of the U.S. Environmental Protection Agency (US EPA) antimicrobial registration process and of the scholarly literature to investigate the current state of the hospital with regards to hospital-acquired infections (HAIs) and whether improvements could be made at the policy level to address this. We reviewed current literature on the national rates of HAIs, current hospital infection prevention practices, and emerging technologies, in particular copper alloy surfaces, that aim to decrease the rate of HAIs. Based on review of these findings, we recommended that antimicrobials for usage in hospital settings be subject to more rigorous regulatory scrutiny, requiring clinical evidence of efficacy if public health claims are made, and we proposed a revised paradigm of registering antimicrobials for use in hospital settings. The second section reports an assessment of the cost-effectiveness and public health benefits of emerging hospital technologies, such as copper alloy surfaces, that have previously been demonstrated to have strong in vitro effectiveness against common hospital pathogens. We compared the cost and performance of standard surfaces with that of copper alloy surfaces based on results from the first clinical study conducted evaluating the in vivo efficacy of copper alloy against common hospital pathogens. With reasonable estimates and data from the literature, our cost-effectiveness model indicated that copper alloy surfaces are a moderately cost-effective strategy for hospitals to adopt in the prevention of HAIs but have minimal incremental effectiveness compared to standard surfaces as measured in quality adjusted life years (QALYs). In the future, this methodology could be used to determine if copper alloy surfaces are a cost-effective strategy for hospitals to adopt based on the availability of more clinical evidence. The third section, addresses a critical gap in the literature on qualitative data on contact isolation precautions for pediatric patients. In this study, we conducted semi-constructed, open-ended interviews with children who were under isolation precautions (or have been in the past) to learn about how this vulnerable population, through their own lens, copes with contact isolation policies to identify areas of improvement in the pediatric isolation experience. Studying the hospital as home to the vulnerable allows a unique opportunity to give voice to key vulnerable populations that are susceptible to hospital-acquired infections (HAIs). Together, these studies highlight the importance of using evidence-based approaches to guide when hospitals should adopt emerging HAI technologies or modify existing interventions and services.