Surveillance

of
Hospital
Acquired Infections
t
 The word “Surveillance”
• The word "sur-veillance"
sur-veillance means
"to watch from above" ("veiller" = "to watch"
and "sur"
sur = above
above")) (i.e.
(i e a God
God's-eye
s-eye view looking
down from on-high).
• The term is often used sed for all forms of
observation, not just visual observation.
• The all-seeing eye-in-the-sky is still an icon of
surveillance in general.
g
 “Eye-in-the-sky"
Note the all seeing
g
surveillance dome
"eye-in-the-sky" in
camera mounted
this London Transport
atop of tall steel
poster
t
pole
 Surveillance
• Surveillance is the ongoing, systematic
collection analysis,
collection, analysis and interpretation of health
data essential to the planning, implementation,
and evaluation of public health practice,
practice closely
integrated with the timely dissemination of these
data to those who need to know.
know

• So that Action can be taken in order to

reduce morbidity and mortality and to
improve health.
health
 Survey, Register and HMIS

„ A surveyy is one data collection episode.

p

„ Register is not for immediate action.

„ Health Management Information Systems

(HMIS) for
f annuall reports.
 Surveillance is:

“Information
“I f i ffor
Action”
 Why Surveillance of HAI?
keyy function of IC team
„Hospital
p acquired
q infections,, with resistant
organisms, are associated with:
¾ Higher
g mortality.
y
¾ Longer hospital stays.
¾ Greater hospital costs.
I fl
Influencing
i F Factors:
t
¾ Microbial agents.
¾ Patient susceptibility
susceptibility.
¾ Medical interventions.
 Wh SSurveillance
Why r ill n off HAI?
ƒ Less th
L than 10% off allll HAI
HAIs occur iin
recognized outbreaks.
ƒ Ongoing surveillance measures the
ENDEMIC rate.
ƒ High endemic rate usually address
MULTIPLE problems.
ƒ There is an “Irreducible
Irreducible Minimum”
Minimum rate of
HAI.
 G l off HAI Surveillance
Goal S ill
„To reduce the incidence of HAIs.
„To detect outbreaks of infection.
„Specific objectives:
¾Disease awareness (CAI
(CAI, HAI)
HAI).
¾Identify areas and populations at risk.
¾Evaluate intervention measures
measures.
¾Assess quality of care.
 Goal of HAI Surveillance
„Surveillance itself increases HCWs’
HCWs
awareness of the diseases and lowers the
risk for occupational infection.
infection.

„Surveillance helps HCWs identify and

correct their high risk practices
practices..

„Surveillance is an entry
y p
point for increased
interest and improvement in infection control
practices..
practices
If HCWs perceive value of information,
information they
rely on data for decisions and will alter
BEHAVIOR..
BEHAVIOR
 Development of
Hospital Surveillance Plan

„Plan should be written (Set).

„Reporting and Analysis of data
(Sense).
„Address
Add major
j problems
bl (A
(Actual
t l#
Desired).
„Outcome
O (Control
(C l Signals).
Si l )
Information = Change
 Importance
p of Good Reporting
p g
Health Care System Public Health Authority

Event Reporting
Data

F db k
Feedback Information
Intervention
 Requirements
• A good network of motivated people.
• Clear case definitions and reporting
mechanism.
• Efficient communication systems.
• Basic and sound training.
• Laboratory support.
• Good feedback and rapid response.
 Challenges
•Communication between laboratories and staff.
•Resistance
R i t t participate
to ti i t ini surveillance.
ill

•Physicians concerned reporting HAIs would

compromise their reputations, and they
questioned the value of conducting surveillance.

•Most SSIs become manifest after the patient,s

discharge from the hospital (30 days after
surgery).
surgery)

•Many patients with infection never return to the

same hospital.
hospital
 S
Some T
Types off S
Surveillance
ill

„ Alert condition surveillance (viral

di h or TB)
diarrhea TB).
„ Alert organism surveillance (MRSA,
MRSA
VRE).
„ Prevalence surveys (single day survey).

„ Incidence
I id surveillance
ill (VAP,
VAP SSI).
SSI)
 Sources of HAI Surveillance
((Passive Surveillance))
„Ward (Daily information):
Number of patients and devices.
Register of patients with infection.
Reports
p from laboratories.

„Hospital:
Daily from each ward to IC office.
Aggregated data to IC committee.
 Elements of surveillance
((Active Surveillance))

„Analysis
A l i andd interpretation
i t t ti off data.
d t

„Identification and description of the

p
problem.

„Definition of the ppopulations

p at risk.

„Conclusion and distribution of reports

reports.
“If
If you thi
think
k
research is
expensive –
try
y disease !”
Mary Lasher (1901-1994)
 Some Famous Studies
„Waiting room (Measles, open TB)
„SARS:
21%
21 % of all probable cases were HCWs.
„Hemorrhagic fevers:
Ebola in Uganda:
g 31%
31% of cases were HCWs.
„Injections are responsible for:
Globally, 5% of all HIV, 32
32%% of Hepatitis B and
40%
40 % of Hepatitis C infections.
Surveillance and training,
not post-
post-exposure
prophylaxis,
p p y
are the basis
for prevention of
occupational infection by
blood-
bl d-borne
blood b pathogens,
th
especially
p y in developing
p g
countries
 Some surveillance indicators
„Hospital Level:
„ P
Proportion
ti off HCW hand
h d hygiene.
h i
„ Proportion of departments performing
appropriate
pp p sterilization.
„ Proportion of departments segregating waste
safely.
„ Needle--stick injuries.
Needle injuries
„ Proportion of HCWs vaccinated with Hepatitis B
vaccine.
 Some surveillance indicators
Targeted Surveillance
„High risk wards (Surgery, ICU, NICU)
¾ Aseptic techniques
techniques.
¾ Reprocessing of instruments.
¾ Waste management
management.
„Types of Infections:
¾ Surgical site Infections (SSI).
(SSI)
¾ Urinary Tract Infections.
¾ Bl d Stream
Blood St Infections
I f ti (BSI).
(BSI)
¾ Respiratory infections.
 When
Wh to t suspectt Infections
I f ti ?
„Surgical infection Purulent
S rgical site infection: P l t discharge,
di h abscess
b
or spreading cellulitis at the surgical site during the month
after operation.
„ Urinary infection: Clinical symptoms and signs, fever
or turbidity of urine.
„Respiratory infection: Respiratory symptoms with at
least two signs: cough, purulent sputum, new infiltrate on
chest ; appearing during hospitalization.
„ Vascular catheter infection: Inflammation,
lymphangitis or purulent discharge at the insertion site.
„ Septicemia: Fever or rigors and at least one positive
blood culture.
Implementation of IC program
¾ Results in high quality safe services.
¾ Reduces infections in patients.
¾ Reduce the risk of HCWs being infected.
¾ Prevents the spread of organisms that are
resistant to antibiotics
antibiotics.
¾ Lowers the cost of health care services.
 Eff t off D
Effect Data
t FFeedback
db k and
d Education
Ed ti
Program on Vancomycin Use

P=.01
160
D o s e s /1 0 0 0 p a tie n t-d a y s 140 132
120 96
100
Before
80
60 After
40
20
0
Yes (9 Units)
ICU-Based Education Program

Fridkin et al, Emerg Infect Dis, 2002

Achievements and indicators of success
Quality of health services
100
90
80
70
60
50 Before
ICP
40
After
30 ICP
20
10
0
Ha PP As Ins Wa
nd E ep tR ste
W Te ep M
c
 Admission and Mortality Rate
in NICUs
1000 0 35
0.35
900
800 0.3
700 Admission

600 0.25
500
400 0.2
Mortality
300 Rate
200 0.15
100
0 01
0.1
Dec Jan Feb March April May June
 Morbidity Rate
“IV cannula site and Urinary Catheter
infections”
80
70
60
50
40
Before ICP
30
After ICP
20
10
0
Cannula Urinary
catheter
Annual HCV Seroconversion of patients
p
in 24 dialysis units

40
35
30
25
20 Before ICP
15 After ICP

10
5
0
Incidence rate
 NNIS S
System
t
ƒ Begun in 1970 with 62 hospitals.
ƒ Now >300
>300 hospitals in 42 states.
states
ƒ Participation voluntary and confidential.
ƒ High quality data used for local performance
improvement.
improvement
ƒ Reduction in national infection rates have been
achieved.
d
*Richards C
C, et al
al. AJIC 2002
 Minimal requirements for
surveillance
„ Monitor infection patterns (sites, pathogens, risk
f
factors).
)
„ Detect changes in the patterns that may indicate an
infection problem.
„ Direct the rapid
p implementation
p of control measures.
„ Monitor antibiotic use and resistance.
„ Provide the staff with exactly the information they
need in order to improve infection prevention
practices.
practices
How to get surveillance information ?

CONFIDENCE
is the most important
principle !!!
Thank you