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From the Front Row: Disease prevention and hospital epidemiology with Dr. Karen Brust

Published on August 19, 2022

This week’s episode features a great conversation with Dr. Karen Brust, the new hospital epidemiologist at University of Iowa Hospitals and Clinics. She talks with Radha and Anya about disease prevention in the hospital setting, the importance of teamwork, changes in the field, and more!

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Radha Velamuri:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Radha Velamuri, and I’m joined by Anya Morozov. If this is your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health and how they are relevant to anyone, both in and outside of the field of public health. Today, we are speaking with Doctor Karen Brust. She recently took on the role of hospital epidemiologist here at the University of Iowa Hospitals & Clinics. Before that, she worked as an infectious disease clinician and director of infection prevention and control at Baylor Scott & White Health. Today, she is going to talk about what exactly a hospital epidemiologist is and what it’s like to prevent the spread of disease in a hospital setting. Welcome to the show, Karen.

Karen Brust:

Hi. Thank you. Thanks for having me. I’m excited.

Radha Velamuri:

Yeah, no. We are, too. To start, could you tell us a little bit about your path, how you became a hospital epidemiologist?

Karen Brust:

Yes. Yeah. It feels a little bit like a windy road. Thinking back at just starting medical school, the first thing I wanted to do was ophthalmology. How I ended up in epidemiology is sometimes lots of several things happened along the way to get me there. I obviously did my training in internal medicine, and then I did my fellowship in infectious disease. And really, I’m not sure that I had envisioned myself on this particular path, but I also didn’t know a lot about it.

Karen Brust:

And so, one of the major things that happened during my fellowship that I think clued me into the world of epidemiology was a health fair event problem. We had a bunch of medical students and some staff physicians that had gone out into an underserved part of the community to do diabetes testing, free testing. And it occurred a very unfortunate event where the needle wasn’t changed in between patient testing. We didn’t know how many people could have been involved. We didn’t know the extent of the potential bloodborne pathogen exposure. And so it became really important for us to do a lot of work really fast to identify at-risk people and to make sure that there wasn’t spread of any communicable disease.

Karen Brust:

The reason that I got roped into it was that it was an underserved area, and so they needed somebody who had a little bit of expertise in the hepatitis B and C world and HIV world, but was also able to speak Spanish to the patients. And so I actually had to conduct all the interviews in Spanish. My mother’s background is Bolivian, so I’m fluent. I conducted all the interviews. We did baseline testing. We ran them through the whole gamut of follow-up testing. We had nobody that ended up exposed by this particular incident, but certainly, it was dramatic and something that needed to be very well taken care of in a very ethical manner. And so it piqued my interest in that point. And so when the outgoing infection control director was about to retire, I think I was the natural person to take the lead. And so that’s how I fell into that position upfront. And this was many years ago now, but since I’ve been doing infection prevention work, I think I’ve really found a tremendous amount of passion for the field.

Radha Velamuri:

That’s such a relevant story. I wasn’t expecting you to have that very direct story that led you to the field, but that would definitely be something that piques your interest, for sure. Before we get into the deep dive, on a lighter note, you just moved to Iowa City. How are you liking it so far?

Karen Brust:

I love it so far. I moved from Central Texas area. Geographically, it’s just very different from where I came from. I love the academic center feel of the University of Iowa. And I don’t know, I almost feel like it’s a city in and of its own within Iowa City. I’m really loving that aspect too. My family’s up here. We figured it was smart to move in the summer and not in the winter since I’m going to have a really hard time this winter. I’m not going to lie. I think somebody needs to probably check on me this winter to make sure I’m doing okay. I do not do well in the cold.

Radha Velamuri:

You’re okay with this 100 degree heat? You’re fine with the 100 degrees, but you’re not-.

Karen Brust:

This heat? This is fine. It’s a little more humid. The heat’s a little more humid than I’m used to, but I am vastly concerned about my mental health during the winter. Yeah. We’ll see how that goes.

Radha Velamuri:

It’s okay. We’re all in this together in Iowa. We are all checking in on each other in the winter. There’s even those lights that people have, the natural light. Yes. So we can get you one of those. Yeah. So Anya and I are actually both studying epidemiology at the University of Iowa. And we know that in general epidemiologists are “disease detectives” looking for causes of disease and how to control and prevent spread. So can you describe how that is in the real world within the hospital setting?

Karen Brust:

Yeah, sure. It’s actually really fascinating. And until you’re doing this work, I’m not sure that people realize what goes on behind the scenes to try to make sure that we’re keeping the hospital environment safe. So we have various layers of investigative work. So our electronic medical record can actually, we can create algorithms and plug in certain data points that we query the electronic medical record. And then we create this feedback that tells us, hey, you might be having a problem with either X type of pathogen or X febrile syndrome. And then the team, because I have a large team here, we’re able to conduct these mini investigations constantly. So, that’s one way that we find problems.

Karen Brust:

Another way that we might investigate an issue is typically we say an astute physician might notice something that is out of the ordinary for them. And I think a great example of that would be when Zika virus hit Brazil. And so all of a sudden they had an increase in the number of microcephalic babies that were being born in Brazil. And so it really, sometimes it takes one physician to say, hey, this doesn’t feel normal. Are you guys seeing something like this? And then broaden the conversation to really, the first thing’s first, to see if there’s actually a problem. And then you dive down deeper into the investigation. And then I think the third mode of finding any pathogen that might be making the environment unsafe is actually active culturing of the environment, which is not done routinely in terms of day to day work, but it is done as needed to make sure that there are no problems. And we do, do it routinely when it comes to water testing to make sure that the water is free from pathogens.

Karen Brust:

So it’s a very interesting work. When we do find the clusters of cases or we do find a bonafide outbreak that is where we do some major investigative work. And I think that would be considered the fun part of the job too, to try to mitigate some of these things.

Anya Morozov:

So just to expand a little further and get a sense of what it’s really like, what are some of the main diseases on your radar at any given time?

Karen Brust:

Well, so I think it depends on what’s happening in the community too. So there’s a community spill over into the hospital. So the obvious examples of that would be COVID, whatever is happening COVID wise in the community is happening inside the hospital. Monkeypox would be something else, something that’s an emerging pathogen, first found in Western Europe, all of a sudden it’s in Canada, the Eastern Coast and now in Iowa. And so we have to keep our eyes and ears open for those types of diseases entering the hospital. But then there’s a whole set of other diseases. These nosocomial infections, these infections that occur within the hospital setting.

Karen Brust:

Those are always on our radar. That is the bulk of the work that we do in terms of infection prevention. Not all of this is glorious work. It’s day to day improvement of practices to try to prevent transmission and pathogens within the hospital, sick patients come to us. And so we have to protect other at risk vulnerable patients. We also, the other facet of our program is to protect the healthcare workers as well. So yeah, there’s a lot of dynamic play between the environment, between the patient, between the healthcare workers. So it is an interesting field of study.

Radha Velamuri:

You said improvements in practice.

Karen Brust:

Yeah.

Radha Velamuri:

Could you maybe give us an example or two. I’m not in the hospital all the time, so I’m not quite sure what a improvement in practice would be.

Karen Brust:

I think it depends on what type of infection that we’re looking at. And typically there’s a whole number of points that you could dig into to try to change practice that then will ultimately impact the patient. And I’m speaking in very vague terms. So let me try to be a little bit more concrete about it. So let’s start with a very simple example. So we try to prevent catheter associated urinary tract infections. So we call those CAUTIs. So what’s one way to not get a CAUTI is to not have a catheter. Seems like a very basic type of thing. But when you have a patient, you can either tackle this by only giving catheters to those patients that absolutely require them. So the indications for use will be high and appropriate, or you can tackle it by removing the fully catheter as quickly as you can. As soon as it’s not being used, it’s not a valuable device to the care of the patient, then it needs to be removed.

Karen Brust:

And so each of those pieces, you could have all sorts of discussions about how to improve just those two little bullet points. And so all these infections come with certain risk factors. And so you try to find where those risk points are and lower those risks, and you do it with process improvement.

Radha Velamuri:

That was super helpful. I need some concrete example, which you gave. So the catheter example was very nice. The other question that I really wanted to ask based on what you talked about previously was you mentioned a couple things that were Iowa specific. Can you compare your experience in Texas with Iowa, the diseases you might see or just different scenarios you faced?

Karen Brust:

Well, so I’ve only been here a couple months, so I guess I should preface by saying that I’m not sure that I’m the Iowan expert yet. I’m still trying to get my feet wet with what’s going on here in Iowa. But I will say that I actually think in general, there’s not much difference. And I’m going to repeat that again, there’s not much difference, because the care that we provide to a patient, it really should be the best quality care that we can provide to the patient. So that has to be true, whether we’re in Texas, whether we’re in Iowa, New York City, the West Coast, whatever. So there is evidence based practices out there that have been shown to reduce some of these infections. And it’s up to us all over the nation to try to make sure that all those practices are being adhered to.

Karen Brust:

And I think that’s really irrespective of what geographic area that you’re working in. I think I encounter physicians or others that they want to say, well in Texas, maybe my obesity population is higher than the rest of the nation. So there are certain specifics with respect to patient population, or even the makeup of your institution, whether or not it might be a private setting with increased resources or an academic setting with increased resources. But in general, I think the fundamentals really should not vary too much place to place. So that’s a very long winded answer, I think, in terms of what you’re looking for.

Anya Morozov:

Yeah, I think I hear a similar thing in the local public health world where there’s going to be differences from county to county based on what population you’re serving, but there’s certain services that should be provided and evidence based practices that should be adhered to. So continuing on with what epidemiology looks like in a hospital setting, clearly it’s not just you working to prevent all infections across the hospital. So what does the team of people that contributes to infection prevention look like in the hospital?

Karen Brust:

I really like this question, because I think if you’re not in this world, you don’t know it. So I will be very Iowa specific on this particular question. So I fall under the department of quality improvement. So we’re under the quality improvement program. We’re called the program of hospital epidemiology. I’m the lead epidemiologist. And I have two associate hospital epidemiologists who are both physicians, both are ID trained, one has additional pediatric training. And so she covers our pediatric side of things. And so there are three of us physicians. And then on top of that, we have eight infection preventionists, and we call them IPS. They have various backgrounds. So they’re not all clinical nurses. Although we do have RNs, MSNs and we have people that are not clinical. So they have backgrounds, MPH, clinical microbiologic sciences. We even have a physician who was a physician in his native country and her native country and are here now working on our team. So we have this amazing, brilliant set of minds that are all trying to work together to reduce hospital acquired infections.

Radha Velamuri:

That’s diversity at its finest, if I do say so myself. So you have your team and with your team, if you were in an ideal world, what would you want individuals, your team, or anyone else within the hospital, or anyone in the community, or anyone in general, what would you hope people would do to prevent the spread of disease within the hospital setting?

Karen Brust:

I think anytime we run into troubles, we constantly hit the reset button and we say back to basics. So I think the answer to that question is how can we get everybody go back to basics? So how can we practice impeccable hand hygiene? We never miss an opportunity to wash our hands appropriately. How do we keep the environment of the patient clean? So it’s not just the physicians and the nurses. Then we have to include the entire environmental services team to keep the room of the patient clean. It comes back to keeping the patient clean. Are we bathing the patient? Are we using the right materials to do that with, are we doing it in an appropriate fashion? Are we doing it in a timely fashion?

Karen Brust:

And the other thing too is sometimes when we’re in the hospital, it becomes our just day to day work. It’s just becomes normal to take care of really sick patients with a lot of lines, with a lot of problems. But we have to remember that we have to do the right thing every time for every patient. And honestly, maybe we don’t think about it all the time, because it would be exhausting and we would all be burned out. But what we try to do is try to figure out how to make it easy on the people that are taking care of these patients to do the right thing every time. So, yeah, I think it’s about back to basics and the pillars of some of these basic infection prevention practices.

Anya Morozov:

That’s really interesting because I think sometimes we can think about all of these cool new innovations, but really you also do have to focus on just the basics and making sure you’re maintaining what you’re already doing as well as maybe thinking about some of the more innovative things. So back to reality and outside of that ideal world where people do the basics, how do you keep up to date about the diseases that are in the hospital, or that may pose a risk to your hospital?

Karen Brust:

Again, I think it’s keeping up with the news. I never envision myself tapping into some of these email notifications to keep on top of the latest news from both internal societies kind of things like the Infectious Disease Society of America or the Society of Healthcare Epidemiology, the journals, I think is another major route to keep on top of the information. I think an important thing that you said just now, and I’m going to reflect back on that. You talked about the shiny new thing. So sometimes there is new information, there’s new literature, there’s new evidence based practice that is hid in the journals. And I think that we have to also be very adaptable. We have to be willing to take what we’ve done and improve on it. So I think this is a current theme, maybe process improvement, but keeping up to date on information, attending conferences with experts in the field, that’s where we find this information to make us progress with what it is that we’re doing.

Radha Velamuri:

Speaking of progression, you’ve been in the field for a while over 10 years. Yeah, that’s crazy. How do you think hospital epidemiology has changed over time?

Karen Brust:

Oh my gosh. And I don’t think I’m that old.

Radha Velamuri:

We’re not trying to imply that you’re old here. 10 years is a lot of experience.

Karen Brust:

It is. And it’s funny because I can remember all the stuff that we used to do in the past. And sometimes I cringe in terms… I can’t believe we used to do that, but I’m not going to use any COVID example, because I think COVID is the quintessential example of things constantly changing and us trying to… So I’ll tap back into something a little bit older. So recently, I call these my fact finding missions, where I go out onto the wards with people and try to figure out what it is that they’re doing. So I actually went with our vascular access team nurses, which is a nurse, a bedside nurse who does this really gorgeous, sophisticated insertion sterile technique of a central line. And I thought to myself, my goodness, we have come a long way. She had this wonderful way of creating this sterile barrier and to try to keep it as sterile as humanly possible during the time of insertion to try to really protect the line from pathogens at the moment of insertion, which is a high risk moment.

Karen Brust:

And I remember being a resident and just not adhering to sterile techniques in that fashion, just putting in femoral lines for example, which are all but non-existent at this point. They’re still being used, don’t get me wrong, but they’re not our go-to line. And when I was training, they were definitely the easiest line to get. They were the ones closest to the groin. So they’re going to be the ones that increased risk of infection, but I was joking with them. I felt like we used to just throw them in from across the room. That’s the sterility that went along with it. And it’s almost embarrassing to talk about, but it’s the truth. We really evolved even in a short decade of time.

Anya Morozov:

And so just for background, the central line, that’s like a needle into a major blood vessel.

Karen Brust:

Yeah, yeah, exactly. So you have to disinfect the skin and then you have to make sure, yeah, the needle goes in the blood vessel and then they thread the catheter over that needle into the blood vessel and then pull out the needle. And then all of a sudden you have several lumens of access to the vasculature of the patient. So you can give a lot of different medications at the same time or fluids or whatever the patient might need. So yeah, very different than how we used to do it.

Anya Morozov:

But if that does get infected, then you have a blood infection basically.

Karen Brust:

Exactly. Yeah. The blood is infected, lots of more antibiotics, more time in the hospital. Exactly.

Radha Velamuri:

Well, since you said it was embarrassing, we won’t make you talk about it much longer. We don’t want you to cringe here from the Front Row. So can we talk a bit more about things that you do like, some skills that you think are important for hospital epidemiologists to have to prevent such cringe events? I can’t believe I said that.

Karen Brust:

So, it’s important to be a strong communicator. So you have to have effective communication to try to get this across to people doing the work. So I think it’s really important to be able to build relationships with people across the hospital setting. So I need to be able to build a strong relationship with my leadership here at the hospital, but I also need to build strong relationships with the person at the bedside who is placing that central line or the nurse that’s caring for that central line, or the person that’s cleaning the room for the patient.

Karen Brust:

These are all critical aspects of the hospital epidemiologist role. I also think that it’s important for me to know that it’s not all on me. I’m just this very tiny little piece in this larger program of hospital epidemiology under this larger program of quality improvement. And there’s a whole group of people that think like me and think it’s important to improve patient outcomes as much as we are able to. So yeah, so just to be a willing participant of the team, it be on top of the evidence and what the literature says. And so we’re not trying to change things that maybe don’t have a lot of evidence behind it.

Anya Morozov:

I like that, being a team player and recognizing yourself and a larger system rather than feeling like it’s all on you.

Karen Brust:

Yeah.

Anya Morozov:

Love it. So based on reading I’ve done, correct me if I’m wrong, you are working as both a hospital epidemiologist and seeing patients in the infectious diseases consult here at the University of Iowa Hospitals & Clinics. Can you talk a little bit about how the hospital epidemiology and the direct clinical care roles are different and how they compliment each other?

Karen Brust:

Sure. And again, I’m going to deep back into my Texas role, because I did have the same dual role back there. And so I can of speak to that a little bit better than what has happened in Iowa so far, but I suspect it’ll be the same experience. So I thought really that it was critical to do the clinical piece of work because it complimented what I was doing in infection prevention. So I think there’s one thing to sit in a room and read a journal and talk about process mapping and process improvement. And there’s another to see what’s happening at the bedside with the workload, with how easy or how difficult it might be to do some of these things and to really just be a colleague in the trenches. I think on some level, I think that, that’s important and it’s important to build relationships out there too, doing the work.

Karen Brust:

One of the most recent examples is obviously the start of the pandemic. So very early in 2020, we had a very small group of ID physicians in my old hospital. There was only six of us. And so I was heavily invested in the planning for COVID and all the PPE, all the personal protected equipment that we were going to be using for the COVID positive patients as they entered the system where we were going to place those patients, what rooms were they going to be in? What was going to be the way that we walked into the unit, the way that we walked out of the unit, what was all the air circulation, everything going into it.

Karen Brust:

And it was by far the busiest time that I’ve had in my career ever. And on top of it, I went in to see patients. Why? Because I needed to know that what we were putting on paper policy wise was feasible. And I had to make sure that the way that we were feeling in terms of our protection going into the patient’s room was adequate. And so all of these things I think really are more complimentary than they are diverse. So I think doing both pieces of work is really the way to do it. I have a hard time envisioning the epidemiology position without the clinical work.

Radha Velamuri:

What I’m hearing is that it helps you keep in touch with reality, not really reality, but it helps you keep in touch with what you’re there to serve in your epidemiologist role. And then in your infectious disease role, you’re getting the background you need to make the more informed epidemiological decisions.

Karen Brust:

Right.

Radha Velamuri:

Yeah.

Karen Brust:

Again, I think it’s being a team player, making sure that policies and guidelines are, A, being adhere to on some level, I get to just be eyeballs on the ground, just to make sure that some of these things that we’re trying to implement are actually being done. And then if they’re not being done, find out the why behind it. And I think sometimes that’s easier when you’re out there and sharing a patient with a nurse. What are the hurdles? What are the barriers to doing the right practice? And sometimes those lines of communication are much more open when you share the care of the patient because you guys know that you’re both on the same team and working towards the same benefit of the patient. And so I get a lot of valuable information when I’m actually taking care of patients at the bedside. Yeah.

Radha Velamuri:

Yeah. Bringing it back to your time in Texas, and now your role here at the University of Iowa. I was wondering what you’re most looking forward to? You’re in a new setting, a new environment, Iowa is not Texas. I’ll say that there’s quite a lot of difference. So is there something that you’re really looking forward to?

Karen Brust:

Yeah. And I’ll keep this more on the professional rather than the personal side, I think. So I think as an outsider, looking at Iowa, this feels like a real promotion to me. The University of Iowa it really, it has a fabulous reputation. There’s so many leaders in the epidemiology world here that I feel like it’s a privilege honestly, to be here. So when I came, I was like, surely this place is perfect. There’s nothing for me to improve on here. And so I was pleasantly surprised and there’s always something to work on. There’s always something to improve.

Karen Brust:

And so I’ve really enjoyed getting to know what the baseline performance around here has been. And so I’m really looking forward to now digging into some of those harder things and trying to really reduce the infections. I’m looking forward to getting to know people, I’m looking forward to getting to working with people on some of these projects that hopefully come together in the end to reduce infections. That’s the overarching goal here. And my team, I feel like I inherited this fabulous team. And so I’m looking forward to getting to know them better and we’re all a bit exhausted from the pandemic. I feel like it needs to be said. Not just my team, everybody, but I’m looking forward to this recovery phase and moving forward together out of the exhaustion phase. So I’m forward to that too. Those little more personal at the end than professional [inaudible 00:32:57].

Anya Morozov:

Oh, I’m glad to hear that you have so much that you’re looking forward to, maybe not Iowa winters, but you’ll get over it.

Karen Brust:

Iowa winters.

Anya Morozov:

But yeah, no, that’s really exciting to hear. And then as we’re wrapping up our last question, we ask it of all of our guests, looking back, I guess, what is one thing you thought you knew, but were later wrong about?

Karen Brust:

I don’t want to harken back to my whole, the way I used to put in femoral lines-.

Radha Velamuri:

It could be personal, it could be professional. It could be anything.

Karen Brust:

Let’s talk about all my failures here now. That’s all right. So, gosh, if you’re not… I’ve already said it. If you’re not learning something, then you’re not progressing. And so it’s, you just have to be adaptable. You have to be ready to shift, pivot, learn, progress. And, oh my gosh, you’re probably looking for one specific example. You want a very concrete example. Well, you know what? I can actually go back to this whole shiny thing. So there was a minute in time where no touch disinfection was all rage. So we had new products to vaporize in the room, or the UV light disinfection. It looks very futuristic. These little robots that come in the room, nobody else is in the room. All the doors are shut. And then it buzzes these lasers around the room and hopefully all the surfaces that it touches, all the germs, just panic and die.

Karen Brust:

So it has this very amazing futuristic quality to it. And I was all in. I heard about this and I was like, this is it. This is the future. This is where I’m going. I’m on board. I’m riding this UV light wave. And it does have its benefits. Please don’t get me wrong. There is good data to support its use. But for example, it’s not that great in a C. diff infection room, where you would think that there was a lot of contamination in the environment, you really want to reduce the burden of microorganisms in the environment. Maybe UV light would be the best thing to be putting in seat of isolation rooms. And the truth is that just a bucket of bleach might work better in those rooms. And so yeah, that was something that I had to be a little bit more calm about and just get back over to bleach. Let’s just get back over to bleach. So there’s your concrete example of a process shift that we did at my old hospital, for sure.

Radha Velamuri:

That’s okay. I’ve succumbed to a couple trends myself in my day. So I totally understand where you’re coming from. Maybe not UV light and robots, but there were some things that I regret for sure. Well, thank you so much for coming on the podcast today. We’ve really learned a lot. I know Anya and I have learned a lot about hospital epidemiology from you, and we really appreciate it as future epidemiologists ourselves. Yeah.

Karen Brust:

Well, good luck to you and your futures.

Radha Velamuri:

Thank you.

Anya Morozov:

Thank you. And that’s it for our episode this week. Big, thanks to Doctor Karen Brust for joining us today. This episode was hosted and written by Radha Velamuri and Anya Morozov, and edited and produced by Anya Morozov. You can learn more about the University of Iowa College of Public Health on Facebook and our podcast is available on Spotify, Apple podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious and take care.