hai = healthcare-associated infection bsi = bloodstream

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ESMIC SHEA Hospital Epidemiology Course 2014 Surveillance: Type, Mode, Practical Issues

Andreas Voss, MD, PhD

Andreas Voss, MD in place of

Loreen A. Herwaldt, MD

¤ HAI = healthcare-associated infection ¤ BSI = bloodstream infection ¤ UTI = urinary tract infection ¤ LRI = lower respiratory tract infection ¤ SSI = surgical site infection ¤ IP = infection preventionist ¤ HCW = healthcare worker ¤ IC = infection control

¤ Careful monitoring and relevant feedback. Data

collection

Data analysis Feedback

Intervention

Process and analyze data

Track down and register NI

Discuss with MDs & RNs

Implement improvement

¤ Internal quality check to op2mize performance ¤ Study on the Efficacy of Nosocomial

Infection Control (SENIC) 1974 ¤ Different combinations of IC practices

reduced infections at each site ¤ Surveillance was the one component

necessary to reduce infections at each site

ESCMID Online Lecture Library

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¤ Determine baseline rates of adverse events ² Healthcare-associated infections

² Falls

² Medication errors

¤ Detect changes in the rates or the distribution of these events

¤ Assess the efficacy of interventions

¤ Prospec2ve mul2-‐centre cohort study, from 1/96 to 12/00 in 37/50 hospitals par2cipa2ng in na2onal surveillance ² 21 920 opera2ons, with 885 (4%) SSIs

Geubels et al Intern J Qual Health Care 2006;18:127-133

year

¤ Decrease of infection during the 4th surveillance year (RR = 0.69; CI95 = 0.52–0.89) and further during the 5th year (RR = 0.43; CI95 = 0.24–0.76)

No significant risk reduction was

observed for patients operated on during the

second and third surveillance years

% SSI

Geubels et al Intern J Qual Health Care 2006;18:127-133

¤ Surveillance reduces SSIs … … but infec2on control teams need to be perseverant and surveillance programs should be given 2me before evalua2on

Geubels et al Intern J Qual Health Care 2006;18:127-133 Create a Surveillance Plan Organizing Surveillance Define

Scope

Definitions Data Sources

Case-finding methods

Reporting Results


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¤  Analyze preliminary data

¤  Evaluate characteristics of the institution

¤  Consider the available resources

¤  Decide which events to study

¤  Evaluate available data sources

¤ Define priorities ¤ Identify clear, specific goals/objectives ¤ Include surveillance components:

² Definitions ² Data sources ² Population surveyed ² Surveillance or case-finding methods ² Data management ² Data analysis and interpretation ² Reporting and feedback

¤ By unit ¤ By infection type ¤ By organism

² Can be prevented ² Occur frequently ² Cause serious morbidity ² Increase mortality ² Increase length of stay ² Are difficult to treat ² Are costly to treat ² Are reportable/required

¤ Bloodstream infection = $40,000 ¤ Urinary tract infection = $ 440 ¤ Vein harvest site after CABG = $ 6,899

UIHC cost data

¤  Written ¤  Applied consistently

¤  Imprecise definitions can lead to incorrect conclusions


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¤ Definitions (examples): ² CDC/ECDC ² Individual country ² Hospital system

¤ How to use: ² Use exactly as written ² Use some of the definitions ² Adapt or modify the definitions

¤ Related to the scope of the program and to the surveillance methods

¤ Examples include: ² All patients ² High risk patients (e.g., in ICUs, surgical) ² Patients with resistant organisms ² Mandated patient populations

¤  Patient’s paper or electronic record

¤  Medication or pharmacy records ¤  Temperature records ¤  Laboratory records ¤  Patient examination ¤  Clinical rounds ¤  Informal conversations with staff

¤ Pharmacy ¤ Radiology ¤ Operating suite ¤ Respiratory Therapy ¤ Admissions

Department ¤ Financial

Management

¤ Emergency Depart. ¤ Outpatient clinics ¤ Home healthcare

agencies

¤ Total chart review ¤ Laboratory reports ¤ Patients on antimicrobial agents ¤ Computerized screening ¤ Post-discharge surveys !!!! ¤ Clinical ward rounds ¤ Combinations of the above


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¤ Total chart review ?? gold standard ¤ Total chart review 74-94% sensitive

² Records did not document all necessary data, e.g., laboratory reports missing

² Records were not available ² Reviewer could not examine patient

¤ Total chart review ² Time consuming ² Review many records for pts without infect

¤ Clinical laboratory reports are a primary source for identifying infections

¤ Results prompt IP to review a chart ¤ Good source for identifying BSIs,

resistant organisms; not good for SSIs, LRIs, (UTIs)

¤ Advantages ² Automatic ² Use data in available databases ² Provides data with little effort after

programming is completed

¤ Disadvantages ² Accuracy of the data in other data bases

cannot be assumed ² Necessary data may not be available in

computer databases

¤ Positive cultures

¤ Positive laboratory findings ² CSF + gram stain, WBC > 5, protein > 45, glucose < 40

² C. difficile toxin test

² RSV antigen test

¤ Combination of diagnostic tests ² CXR and respiratory culture/24 hrs

² Cultures from > 2 body sites/24 hrs

¤ Incidence (new cases) vs. Point prevalence (existing cases)

¤ Outcomes (infections) vs. Process (processes related to infections)

¤ Combinations

¤  Critical/intensive care units

¤  Units with high infection rates ¤  Patients at high risk of infection

¤  Patients with particular devices

¤  Specific organisms


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¤  Epidemics are common

¤  Antimicrobial resistance common ¤  Infections are often device related and

might be preventable

¤  Surveillance efficiency high: ICUs have 8% of hospital beds but 33-45% of HAIs

¤ Advantages ² Simplifies surveillance

² Uses limited resources in high-risk areas

² Focuses on high risk areas or populations

² Enables the infection control program to prevent infections in patients at highest risk

² Allows IP to do other tasks

¤ Disadvantages ² Have data only on targeted patients,

units, risk factors, or organisms

² Miss infections in non-surveyed areas

² May miss clusters or outbreaks in non-surveyed areas or populations

¤ Entire Hospital ² BSI ² CLABSI ² CAUTI ² C. difficile ² Clusters ² Hand hygiene

¤ Surgical Services ² SSI ² Door openings

¤ ICUs ² VAP

¤ Pediatrics ² RSV

¤ Entire Hospital ² MRSA

¤ ICUs ² BSI ² VAP

¤ Yearly prevalence survey of all nosocomial infections

¤ Intermittent surveys of compliance with hand hygiene

point-‐prevalence – Data-‐collec2on on one day

As of 1-‐1-‐12

Stopped at 1/1/2012

Prospec2ve incidence surveillance http://www.prezies.nl

Prospec2ve incidence surveillance


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http://www.prezies.nl Different kind of procedures

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1 2 3 4 5 6 7 8 9 10 11 12

# of

hos

pita

ls

% of SSIs

CTG 38567 Total hip

P25 P75 Your hospital

PREZIES Module SSI Example of feedback

¤ Supplements case finding on inpt units ¤ Useful for SSI & infections of implanted CVCs,

PICCs, dialysis catheters

¤ See patients; read notes of clinic or ER visits; contact MDs or patients by phone or mail, computer screening

¤ Studies of postop patients, postpartum women, neonates

¤ No method has been widely accepted

In-pt Post-discharge

Results ¤ 111 SSI occurred

after discharge ¤ 70 SSI were

diagnosed and treated entirely outside of the hospital

Sands, JID, 1996


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¤ Monitoring practices that directly or

indirectly contribute to a health outcome ¤ Using data to improve process and

possibly the outcome ¤ Adjunct to surveillance for HAIs ¤ Use as a surrogate for outcome

assessment or combine with outcome data`

¤ Process should be associated with the designated outcome ² Urinary catheter care bundle ² Central-line bundle ² Hand hygiene ² Door openings in operating room

¤ Concurrent or retrospective ¤ Collect only necessary data ¤ Record data in a systematic format ¤ Organize data in a meaningful way

² Cards: 1 card per infection or patient ² Flow sheet or linelist ² Computer database

¤ When ² Regular intervals ² When special circumstances arise

¤ To whom ² Clinical Departments ² Nursing units ² Infection Control Committee ² Other Committees ² Upper level administrators

Evaldson, et al. Acta Obstet Gynecol Scand 1992;71:54-58.

0

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14

16

%

Pre Post

All nosocomial infectionsWound infectionEndometritis post C-section

Infection rates before and after regular feedback of infection rates. *p<0.05

*

*

*

*


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¤ How and What ² Graph rates over time ² Tables with the number of

infections, the denominators, & the rates over time

² Linelist of affected patients ² Assessments and conclusions

¤ Did system detect clusters or outbreaks?

¤ Were data used to: ² Change patient care practices?

² Decrease endemic rate? ² Assess interventions?

² Ensure that rates did not increase when P/P changed?

¤ Comparisons are valid only if all parties ² Used the same definitions ² Used the same surveillance intensity ² Used the same data collection methods ² Risk-adjusted for differences in population

¤ Garbage in = garbage out

I will not even start with talking about public repor2ng …

TESTED THE BEST Good choice! Hospital with

lowest infection rate after

surgery

“Yah, but there is a slight drawback. Most patients here do NOT

survive surgery to get infected.”

See, this is where I should go !


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¤ Systematic differences in the way surveillance is done ² Differences over TIME ² Differences among PLACES

¤ Different case definitions ¤ Different interpretations of the same case

definition ¤ Different effort used to find patient with

HAIs Break-thro ugh project

"   The na2onal surveillance indicated major differences with regard to SSI between hospitals à this indicates that further reduc2on of SSI must be possible in many hospitals

Breakthrough projects

“Gap between what we know and what we do”

Implementa2on of exis2ng

knowledge

Infection control Surgeons

Nurses

Administrator

Infection Control Anesthesiologist

Surgeon


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8-15 multidisciplinair samengestelde teams afkomstig uit verschillende zorginstellingen en/of regio’s in Nederland vormen een tijdelijk samenwerkingsverband. Al deze teams werken aan het optimaliseren van de zorg op hetzelfde onderwerp of zorgproces. Binnen het centrale onderwerp of zorgproces formuleren de teams hun eigen doelstelling. Tijdens het Doorbraakproject worden de teams begeleid door inhoudelijk en methodische deskundigen. Veel aandacht wordt hierbij besteed aan het meten van resultaten (indicatoren).

Breakthrough projects

"   Exchange experience and control of local projects during na2onal group mee2ngs "   Na2onal advisory team "   Measure outcome solely to evaluate project "   Change process parameters to achieve be\er outcome

PLAN

DO STUDY

ACT

Outcome indicator e.g. # SSIs

Hair removal

Discipline during OP Antibiotic-prophylaxis Process indicators

Breakthrough project: Method

"   Number of door movements and number of people in the OR "   AB-‐prophylaxis

(choice of drug, 2ming, number of doses)

"   Wound care "   Hair removal "   Body temperature

0123456789

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Number of observations

Intervention ¤  Implement real changes

“If you keep doing what you always did, you will keep gecng what you always got”

Thus, if you want to “achieve more” you have to change your technique


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Jump high = change your technique

“Western roll”

“Fosbury”

“Traditional”

¤ Surveillance will reduce nosocomial infec2ons ¤ Any improvement of surveillance projects will take 2me to show an effect

¤ Surveillance (QI) should be a con2nuous process ¤ Surveillance of outcome indicators alone is no more sufficient and/or possible ² Use process indicators to influence behaviour and monitor effect of interven2ons

² Changes in care (day-‐surgery, reduced 2me of admission) make surveillance of outcome indicators difficult

•  One flue patient can cause an epidemic •  One yawn can causes lots of other yawns •  One surveillance project can reduce infections


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hai = healthcare-associated infection bsi = bloodstream

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