Surveillance of nosocomial infections

Johnny, Courtesy, Brocolli

Nosocomial infections (NCI)

"nosus" = disease
"komeion" = to take care of
Infections that occur during hospitalization
but are not present nor incubating upon
hospital admission

Characteristics of hospitals

Treatment is main focus

Many stakeholders
Shift work
A lots of data, easily defined cohorts
Different patient population
Variation of length of stay
Vulnerable patients
Community vs. hospital

The problem of NCI

USA

Urinary tract infections: 2.4 per 100 admissions

Pneumonia: 1 case per 100 admissions
Surgical site infections: 2.8 per 100 operations
NCI; one death every 6th minutes

Norway
One of 19 patients have a NCI

The problem of NCI

Regional hospital, Zimbabwe:
1 of 6 developed SSI

2 referral hospitals, Ethiopia:

38.7% developed SSI
14 of 18 deaths attributed to SSI

Cost of NCI
England
Average cost per NCI: 3.000 pounds
Extra days:
Urinary tract infections:
Pneumonia:
Surgical site infections:

6
12
7

Why surveillance?
NCI cause of morbidity and mortality
One third may be preventable
Surveillance = key factor
an infection control measure
overview of the burden and distribution of NCI
allocate preventive resources

Surveillance is cost-efficient!!

The surveillance loop

Health care
system

Surveillance
centre
Reporting

Data

Action

Information

Feedback,
recommendations

Analysis,
interpretation

Event

Considerations when creating a

surveillance system
Goal of the surveillance system (why)
Engage the stakeholders (who)
Surveillance method (what, how, when)
definition
what to collect
how to collect (operation of system)

Available resources

I may not have gone where I intended to go,

but I think I have ended up
where I needed to be
Douglas Adams

Objectives

Reducing infection rates

Establishing endemic baseline rates
Identifying outbreaks
Identifying risk factors
Persuading medical personnel
Evaluate control measures
Satisfying regulators
Document quality of care
Compare hospitals NCI rates

Who
All hospitals?
All departments?
All specialties?
Other health institutions?

Stakeholders
Central
adm.

..

Local
adm.

Public
Health
instituteI

Directorat

ICP

Itdep.

Surveillance of
surgical site infections

Ministry
Of health

Surgical
wards
Service
dep.

Surgical
ward. 2
Lab

Patients

Surveillance of one or more types of NCI

Urinary tract infections
Lower respiratory tract infections
Surgical site infections
Bloodstream infections
Conjunctivitis
Others

Targeted surveillance
Special patient population
(surgical, medical, paediatric, intensive)

Diagnostic and therapeutic procedures

(endoscope, haemodialysis, catheterization,
blood transfusion)

Specific pathogens
(staphylococcus aureus, MRSA,
clostridium difficile, norovirus)

Variables
Administrative data
Id, address, dates of admission, discharge..

Patient related factors:

Age, sex, severity of underlying disease

Procedures
Surgery
Devices (e.g. catheters)

Treatment, diagnosis
Use of antibiotics

Stratification points,
surgical site infections

When?
During hospital stay?
Frequency of data collection

After discharge?
When and how?

How?
Two main surveillance methods
incidence
prevalence

Variations within these methods

Incidence (cohort) studies

marching towards outcomes

Cohort design
Prospective
Exposed
PAR

Study
group
Not exposed

NCI
Not NCI
NCI
Not NCI

NCI
PAR =

Population at Risk

Time period

Retrospective

Measure
Percentage
#NCI / # patients

Incidence density
Patient-days as denominator

Risk factors
RR=

risk in patients exposed

risk in patients not exposed

Positive aspects

Provide information on several risk factors

Exposure measures before outcome
Information on consequences of NCI
Can identify outbreak
Ongoing attention

Limitations

Resource demanding
Loss of follow-up
Seldom NCI
Confounding and bias is possible

Prevalence
Measures number of current NCI
Within a defined population at risk
At a given time
#NCI / #patients at risk *100
Point or period prevalence

Use of prevalence surveys

Show trends
Estimate

distribution of NCI
surveillance accuracy
incidence from prevalence??
antimicrobial usage patterns

Rise awareness

Limitations

Do not identify causes

Duration of NCI affects the prevalence
Not very suitable for small institutions
Difficult to adjust prevalence

Prevalence survey

Incidence surveillance

UTI n=6
SSI n=2

Define method
Identify and review
Protocols used elsewhere e.g.
HELICS incidence, Norway's prevalence
Literature

Minimum dataset

Methodological issues
Definitions
NCI
Cut off 48 or 72 hours?
Criterias from Centers for Disease Control and Prevention (hospital)
McGeer (long-term care facilities)
Risk variables
Case finding
Active or passive
By whom?
After discharge?
Prospective or retrospective?

Case finding
Active: by surveillance personnel
Passive: by medical personnel
Laboratory or clinical based
Source of data
Clinical examinations
Medical records, reports from laboratories
Forms or interviews

Ongoing systematic collection?

Cohort
Continual?
Periodical?

Prevalence
Weekly?
Yearly?
Depends on objectives

Precision of estimate
Number of patients
under surveillance
50
100
100
200
1000
3500
8000

Number of Incidence (%) 95% confidence

NCI
interval
3
6% (1,3% - 17%)
3
3% (0,6% - 8,5%)
5
5% (1,6% - 11%)
20
10% (6,2% - 15%)
50
5% (3,7% - 6,5%)
100
3% (2,3% - 3,5%)
320
4% (3,6% - 4,5%)

Dummy table

Implementing surveillance system

Administrators responsibility
Involvement of stakeholders
Identify available resources

Personnel
Money
Time
Equipment
It- solutions

Realistic project plan

Organization map
Making forms and letters
It-solutions
Training
Use of data

Making surveillance work

Support by the administrators

Involve local experts
Simple
Minimize resources required by hospitals
Training
Feedback and use of data
Flexibility

Training topics
Why surveillance?
How?

Definition
Case finding
Case studies
It-solution

Use of data

Quality controls
Define acceptable loss of follow-up
Make sure all patients are included
Identify infections
Use several sources
Compare data, conduct surveys
Training

Clean data
Completeness
Logical values

Use of data
Prevent NCI
Ward audits
Present data to hospitals, administrators,
MoH, patients
Argument for resource allocation
Audits for medical personnel
Raise awareness

Incidence of SSI over time

Conclusion

Hospital

Pathogen

Unhappy
patients

Unhappy
director

Hospital

Surveillance

Happy
Patients

Happy
director