WHY PERFORM SURVEILLANCE IN LONG-TERM CARE FACILITIES?

1. LECTURE 1 WHY PERFORM SURVEILLANCE IN LONG-TERM CARE FACILITIES?

2. LECTURE OBJECTIVES • To introduce concepts of surveillance • To describe types of surveillance: prevalence versus incidence • To distinguish between colonisation and infection • To define Healthcare-associated Infection (HAI) • To outline the HALT Point Prevalence Survey (PPS) • To provide results of HALT 2010 project • To outline the lessons learnt from HALT 2010

3. SURVEILLANCE What is surveillance? • Systematic collection and analysis of data and the use of this information for actione.g. • Improve care to patients/residents • Reduce the occurrence of preventable healthcare- associated infection (HAI) • Compare with other facilities with same resident mix

4. SURVEILLANCE • Fundamental part of infection prevention & control but requires resources and skilled personnel • 2 main types of surveillance used in healthcare • Incidence • Prevalence

5. TYPES OF SURVEILLANCE Incidence • Provides ongoing data on all organisms, infection sites and wards • Often used selectively on a specific site of infection e.g. • Surgical site surveillance • Infections associated with central venous catheters

6. TYPES OF SURVEILLANCE Point Prevalence • “Snap shot” at a specific point in time e.g. one day • The number of residents with the ‘condition of interest’ (e.g. healthcare-associated infection) divided by the total population at a specific point in time

7. WHAT IS AN INFECTION? • Signs and symptoms of an infection varies depending on the site • Common signs include: • Pyrexia • Inflammation • Pain • Presence of pus • General malaise

8. COLONISATION IS NOT INFECTION • Colonisation • Microbes live on/in the body without any ill effects e.g. • S. aureus including MRSA in the nose or on the skin • E. coli (bowel) • Includes microbes that are present in the urine of long-term catheterised patients but are not causing an infection

9. WHAT IS A HEALTHCARE – ASSOCIATED INFECTION (HAI)?

10. An infection that someone gets after being in hospital or in contact with the healthcare system e.g. being in a long-term care facility

11. ‘Healthcare-associated infection’(HAI) is gradually replacing the terms ‘nosocomial infection’ or ‘hospital-acquired infection’. • In the past: most complex patient care occurred in hospitals = where most of the infections occurred. • Now: patients treated in a variety of settings, including long-term care facilities, primary care etc.

12. WHAT IS THE HALT POINT PREVALENCE SURVEY (PPS)? HALT-2 PPS is looking at the prevalence of: • Healthcare-associated infection 2. Antimicrobial use 3. Antimicrobial resistance 4. Infection prevention and control resources and practices

13. HOW IS PREVALENCE MEASURED?

14. PREVALENCE (e.g. for antimicrobial use) Total population of Long-Term Care Facility Ineligible resident Admitted less than 24 hrs ago Denominator:Eligible residents Numerator:Number of residents on antimicrobials

15. PREVALENCE Numerator:Number of residents on antimicrobials 3 9 Denominator:Eligible residents Prevalence = 3 ÷ 9 = 0.33 x 100 = 33% i.e 33% of residents are on antimicrobials on the study day

16. EXAMPLES Prevalence of Healthcare-associated Infections (HAI) Survey population: A No. of patients with HAI on day of survey: B Prevalence = B/A x 100 = C%

17. EXAMPLES Prevalence of antimicrobial use Survey population: A No. of patients receiving antimicrobials on day of survey: B Prevalence = B/A x 100 = C%

18. HOW DO YOU MEASURE INFECTION DURING SURVEILLANCE? • Standardised definitions • Need specific number of signs/symptoms to “fit” this definition • NOT the same as clinical diagnosis

19. WHAT IS A HEALTHCARE- ASSOCIATED INFECTION (HAI) FOR HALT-2? An active healthcare-associated infection present on the day of the survey is defined as follows: “An infection is active when signs and symptoms of the infection are present on the survey date or signs and symptoms were present in the past and the resident is (still) receiving treatment for that infection on the survey date. The presence of symptoms and signs in the two weeks (14 days) preceding the PPS day should be verified in order to determine whether the treated infection matches one of the case definitions of healthcare-associated infection.”

20. HALT HAI – IMPORTANT CONSIDERATIONS - 1 • The onset of the symptoms should have occurred 48h after the resident was admitted or re-admitted to the LTCF (excluding infections already present or in incubation at the time of (re-)admission). • Note: Surgical site infections should be excluded from this study if the onset of the symptoms took place within 30 days of the operation or within one year in surgeries involving an implant. In these situations, the surgical site infections are considered as hospital-acquired.

21. HALT HAI – IMPORTANT CONSIDERATIONS- 2 • All symptoms must be new or acutely worse. - Many residents have chronic symptoms, such as cough or urinary urgency, that are not associated with infection. - However, a change in the resident’s status is an important indication for infection in development.

22. HALT HAI – IMPORTANT CONSIDERATIONS-3 • Non-infectious causes of signs and symptoms should always be considered before a diagnosis of infection is made. • Identification of infection should not be based on a single piece of evidence. Microbiological and radiological findings should be used only to confirm clinical evidence of infection. Similarly, physician diagnosis should be accompanied by compatible signs and symptoms of infection.

23. EXAMPLE: URINARY TRACT INFECTION • Acute dysuria • Acute pain/swelling or tenderness of the testes, epididymis, or prostate • Fever (> 38oC) or leukocytosis • Acute costovertebral angle pain • Suprapubicpain/tenderness • Gross hematuria • New or marked increase in frequency • New or marked increase in urgency • New or marked increase in incontinence How many of these symptoms mean that a UTI is present?

24. EXAMPLE: URINARY TRACT INFECTION

25. EXAMPLE: URINARY TRACT INFECTION

26. EXAMPLE: URINARY TRACT INFECTION Exhaustive searching of signs/symptoms present in residents is crucial in order to be able to confirm infections.

27. Why SHOULD A COUNTRY PERFORM SURVEILLANCE IN its LONG-TERM CARE FACILITIES?

28. Growing demand for long-term care (LTC) due to ageing population. • The number of long-term care facility residents that require complex care is also increasing. • Residents of long-term care facilities play an important role in the epidemiology of antimicrobial resistant microorganisms. • The frequency of infections is comparable to that in acute care.

29. Decline in length of stay in acute care hospitals – individuals are being discharged into the community earlier and presenting with healthcare-associated infections (HAI). • Accurate information on infections and antimicrobial resistance and use is crucial to increase awareness and to put strategies in place to reduce preventable healthcare-associated infection and inappropriate antimicrobial use.

30. …….lots of benefits! Why should my LOCAL LONG-TERM CARE FACILITY takE part IN HALT -2?

31. Get information on HAI, antimicrobial use and infection control practices/resources. • Benchmark against other long-term care facilities with similar patient mix. • Allows your long-term care facility to plan (based on facts) improvements in patient care e.g. education/ development of policies/resources allocation. • Study can be repeated to track improvements. • Educates your staff on HAI, antimicrobial use & surveillance.

32. WHAT DID WE FIND IN HALT-1 2010?

33. PARTICIPATING COUNTRIES 28 countries, 722 LTCFs Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Lithuania Luxemburg Malta Poland Portugal Slovenia Spain Sweden The Netherlands UK: England Scotland Wales Northern Ireland n° eligible residents: < 250 250 - 499 500 - 999 1000 - 4999 > 5000 Total LTCF-beds: 67 613 beds Mean LTCF size: 94 beds (9 – 695 beds) Total eligible population: 63 884 r. (94.5%) KatrienLatour ARHAI 2011

34. ANTIMICROBIAL USE Crude prevalence: 4.3% Mean prevalence: 4.9% [Md: 3.4%, 95% CI 4.8% - 5.1%] KatrienLatour ARHAI 2011

35. Crude prevalence of residents with HAI (/100 ER) 0 - 0.99 1 - 2.99 3 - 4.99 5 - 6.99 >7 HEALTHCARE-ASSOCIATED INFECTIONS According to modified McGeer criteria Crude prevalence: 2.40% Mean prevalence: 2.55% [Md: 1.53%, 95% CI 2.43 – 2.67%] KatrienLatour ARHAI 2011

36. LESSONS LEARNT FROM HALT-1 • Provided a baseline for many countries who did this for the first time • Raised awareness for Long-Term Care(less resources & expertise) • Use of data! • Identify priorities for further research • National and local initiatives • Seasonal influence KatrienLatour ARHAI 2011

37. WHY ARE WE REPEATING HALT? • Increase the number of participating countries and facilities • Improve quality of data on HAI, antimicrobial use and infection prevention and control practices and resources • Promote education, training and development of guidelines • Ultimately improve patient care