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Surveillance of nosocomial infections

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.

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Surveillance of nosocomial infections

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  1. Surveillance of nosocomial infections Johnny, Courtesy, Brocolli

  2. Nosocomial infections (NCI) "nosus" = disease "komeion" = to take care of Infections that occur during hospitalization but are not present nor incubating upon hospital admission

  3. 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

  4. 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

  5. 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

  6. Cost of NCI England • Average cost per NCI: 3.000 pounds • Extra days: Urinary tract infections: 6 Pneumonia: 12 Surgical site infections: 7

  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!!

  8. The surveillance loop Health care system Surveillance centre Data Information Event Action Reporting Analysis, interpretation Feedback, recommendations

  9. 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

  10. I may not have gone where I intended to go, but I think I have ended up where I needed to be Douglas Adams

  11. 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

  12. Who • All hospitals? • All departments? • All specialties? • Other health institutions?

  13. Stakeholders

  14. Surveillance of one or more types of NCI Urinary tract infections Lower respiratory tract infections Surgical site infections Bloodstream infections Conjunctivitis Others…

  15. 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)

  16. 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 ……

  17. Stratification points, surgical site infections

  18. When? • During hospital stay? • Frequency of data collection • After discharge? • When and how?

  19. How? • Two main surveillance methods • incidence • prevalence • Variations within these methods

  20.  Incidence (cohort) studies marching towards outcomes

  21. NCI Not NCI Not NCI NCI Cohort design Prospective NCI Exposed T Study group PAR Not exposed T PAR = Population at Risk T = Time period Retrospective

  22. Measure • Percentage • #NCI / # patients • Incidence density • Patient-days as denominator • Risk factors RR= risk in patients exposed risk in patients not exposed

  23. Positive aspects • Provide information on several risk factors • Exposure measures before outcome • Information on consequences of NCI • Can identify outbreak • Ongoing attention

  24. Limitations • Resource demanding • Loss of follow-up • Seldom NCI • Confounding and bias is possible

  25. 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

  26. Use of prevalence surveys • Show trends • Estimate • distribution of NCI • surveillance accuracy • incidence from prevalence?? • antimicrobial usage patterns • Rise awareness

  27. Limitations • Do not identify causes • Duration of NCI affects the prevalence • Not very suitable for small institutions • Difficult to adjust prevalence

  28. Prevalence survey UTI n=6 SSI n=2 Incidence surveillance

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

  30. 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?

  31. 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

  32. Ongoing systematic collection? • Cohort • Continual? • Periodical? • Prevalence • Weekly? • Yearly? • Depends on objectives

  33. Precision of estimate

  34. Dummy table

  35. 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

  36. Making surveillance work • Support by the administrators • Involve local experts • Simple • Minimize resources required by hospitals • Training • Feedback and use of data • Flexibility

  37. Training topics • Why surveillance? • How? • Definition • Case finding • Case studies • It-solution • Use of data

  38. 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

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

  40. Incidence of SSI over time

  41. Conclusion Pathogen Unhappy patients Unhappy director Hospital Surveillance Happy Patients Happy director Hospital

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