Screening and Surveilance NI

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: 6
Pneumonia: 12
Surgical site infections: 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 Surveillance
system centre

Reporting
Event Data

interpretation
Analysis,
Action Information
Feedback,
recommendations
 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
 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 ICP
instituteI

It-
Directorat
Surveillance of dep.
surgical site infections

Ministry Surgical
Of health wards

Service Surgical
dep. 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

NCI
Exposed T
PAR Study Not NCI
group
Not exposed NCI
T
Not NCI
NCI
PAR = Population at Risk
T = 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

UTI n=6
Incidence surveillance 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 Number of Incidence (%) 95% confidence

under surveillance NCI interval
50 3 6% (1,3% - 17%)
100 3 3% (0,6% - 8,5%)
100 5 5% (1,6% - 11%)
200 20 10% (6,2% - 15%)
1000 50 5% (3,7% - 6,5%)
3500 100 3% (2,3% - 3,5%)
8000 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 Unhappy

patients director

Hospital Surveillance Happy Happy

Patients director