Book
Surveillance of Healthcare associated Infections in Healthcare Facilities
- Recommendations
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Recommendations |
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Monitor the incidence of epidemiologically-important organisms and targeted HAIs that have substantial impact on outcome and for which effective preventive interventions are available; use information collected through surveillance of high-risk populations, procedures, devices and highly transmissible infectious agents to detect transmission of infectious agents in the healthcare facility. (Strong Recommendation, High Grade Evidence) |
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Apply the following epidemiologic principles of infection surveillance: Use standardized definitions of infection - Use laboratory-based data - Collect epidemiologically-important variables (e.g., patient locations and/or clinical service in hospitals, population-specific risk factors [e.g., low birth-weight neonates], underlying conditions that predispose to serious adverse outcomes) - Analyze data to identify trends that may indicate increased rates of transmission - Provide feedback information on trends in the incidence and prevalence of HAIs, probable risk factors, and prevention strategies and their impact to the appropriate healthcare providers, organization administrators, and as required by local and state health authorities (Strong Recommendation, Moderate Grade Evidence) |
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Steps should be taken in hospitals to ensure that case definitions are consistently and accurately applied. : (Strong Recommendation, Moderate Grade Evidence) |
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Active surveillance should be used for surveillance programs in hospitals because of the higher sensitivity associated with this approach to case finding. : (Strong Recommendation, Moderate Grade Evidence) |
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Use standardized methodology for performing device associated infections surveillance; the number of infections per 1,000 device days or device utilization ratio (Strong Recommendation, Moderate Grade Evidence) |
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Rates of device-associated infection that are adjusted for duration of exposure to the device should be calculated. (Strong Recommendation, Moderate Grade Evidence) |
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Perform surveillance for SSI. (Strong Recommendation, Moderate Grade Evidence) |
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Develop and implement strategies to reduce risks for transmission and evaluate effectiveness. (Strong Recommendation, Moderate Grade Evidence) |
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When transmission of epidemiologically-important organisms continues despite implementation of infection prevention and control strategies, obtain consultation from persons with infection prevention and control, infectious disease, healthcare epidemiology knowledge to review the situation and recommend additional measures for control (Strong Recommendation, Moderate Grade Evidence) |
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The surveillance process implemented in a facility (e.g., application of case definitions, case finding and communication methods) should be regularly reviewed and modifications made as needed. At least annually, the outcomes of surveillance systems (i.e., reductions to the risk of infection) should be reviewed and system objectives re-aligned as required. (Strong Recommendation, Moderate Grade Evidence) |
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Review periodically information on community or regional trends in the incidence and prevalence of epidemiologically-important organisms as per Egyptian Law and Regulation of Preventive Sector of Ministry of Health (including in other healthcare facilities) that may impact transmission of organisms within your facility (Good Practice Statement) |
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Calculate and analyze prevalence and incidence rates of targeted MDRO infection in populations at risk (Strong Recommendation, Moderate Grade Evidence) |
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Include only one isolate per patient, not multiple isolates from the same patient, when calculating rates (Good Practice Statement) |
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Increase the frequency of compiling and monitoring antimicrobial susceptibility summary reports for a targeted MDRO as indicated by an increase in incidence of infection or colonization with that MDRO. (Good Practice Statement) |
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Monitor trends in the incidence of target MDROs in the facility over time using appropriate statistical methods to determine whether MDRO rates are decreasing and whether additional interventions are needed. (Strong Recommendation, High Grade Evidence) |
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In all healthcare organizations, establish systems to ensure that clinical microbiology laboratories (in-house and out-sourced) promptly notify infection control staff when a novel resistance pattern for that facility is detected. (Strong Recommendation, Moderate Grade Evidence) |
Rationale
It is estimated that most HAIs are preventable. Therefore, an infection prevention and control (IPC) program that is effective in preventing HAIs can substantially reduce health care costs and, more importantly, the morbidity and mortality associated with HAIs. An effective surveillance system will reduce the frequency of health care-associated infection. The general steps required in setting up a surveillance program can be followed by any hospital or long-term care home in planning and implementing their surveillance system:
1. Assess the population to be surveyed: This evaluation enables priorities for a surveillance system to be established. Resources for surveillance can then be targeted to the populations at risk for the outcomes of greatest importance, defined in these priority areas.
2. Select the outcome(s) for surveillance: Facility-wide surveillance, while comprehensive, requires considerable time and personnel resources. There is no value to identifying infections for surveillance purposes unless the results may be used to effect change that will result in lower HAI rates. Facility-wide surveillance will identify many infections that cannot be prevented, wasting valuable resources that may be used for other purposes, such as education. Prioritization of the types of infections to be surveyed will assist the Infection Control Professionals (ICPs) to make the best use of the available resources while having the greatest impact on the populations that they serve.
3. Use standardized, validated case definitions for infection that is consistent over time: In any surveillance system, all elements of the data that are being collected need to be clearly defined, including the infection outcome, the ‘at risk’ population and other risk factors for infection. The recommendation for hospitals is to use standardized, validated case definitions for surveillance, to allow for comparability. For example, the National Healthcare Safety Network (NHSN) program’s case definitions are widely used in hospital surveillance programs worldwide and provide benchmarks for comparison. Infection Control Professionals should receive training in the consistent and correct application of case definitions for surveillance
4. Collect the surveillance data: Data collected on a daily basis by ICPs using standardized methodology and case definitions. Health care-associated infections are expressed as a rate, i.e., the number of cases related to the number of persons at risk over a particular period of time. Using standardized forms, the elements required to generate these HAI rates in the specific time period involved.
o Numerator- the number of cases (i.e., persons developing a particular infection)
o Denominator- number of persons at risk (i.e., population at risk for development of that infection)
o Specific forms for each infection type and locations to calculate the rates of each unit involved in the surveillance
5. Calculate and analyze surveillance rates: Calculating incidence rates involves compiling individual level patient/resident data and then aggregating it into a summary of the risk for developing a HAI within a population of patients over a specified time-period. It is better to adjust rates of HAIs for patient/resident length of stay by using the number of patient/resident days as the denominator, rather than number of admissions or number of beds, also for exposure to medical devices and for type of surgical procedure in the hospital setting.
6. Apply risk stratification methodology where applicable: Patients served by differing health care settings have differing risk factors related to the treatments and procedures that they undergo. These risk factors may be either extrinsic (e.g., environment-related) and/or intrinsic (patient-related) risk factors for HAI, including underlying disease condition and advanced age. Without adjustment for these factors, comparisons within the same health care setting or inter-facility comparisons may be invalid or misleading interpret HAI rates. Risk stratification allows for meaningful comparison of rates among patients/residents with similar risks within a health care setting or between health care settings and at different points in time.
● Common methods used for risk-adjustment in HAI surveillance:
- Stratification by location in surveillance of device associated infections
- Stratification by surgery type in SSI surveillance
- Stratification by risk index category in SSI surveillance
- Stratification by birth weight group in neonatal CLABSI and VAP
- Stratification by type of central line in CLABSI in specialty care areas
- Standardized infection ratio
7. Interpret Infection Rates: Infection Control Professionals must be able to interpret HAI rates so that they can identify areas where improvements to infection prevention and control practices are needed to lower the rate of infection, or to evaluate where preventive interventions have been effective in reducing the risk of infection. Interpreting the meaning of a rate of infection requires a close working knowledge of how one’s surveillance system operates and noticing if a rate deviates substantially from previous surveillance periods
8. Communicate and use surveillance information to improve practice: If surveillance data are not used to effect changes to IPC practices, then the surveillance system is not working. Distribution of surveillance data is both verbal and visual, and their usage as an input to IPC practice constitutes the end goal of an effective surveillance system. A surveillance system that simply collects and houses data without being delivered to stakeholders don’t attain the main goal, that of improved IPC practice and decreased rates of HAIs.
9. Evaluate the surveillance system: The surveillance process implemented in a facility (e.g., application of case definitions, case finding and communication methods) should be regularly reviewed and modifications made as needed. At least annually, the outcomes of surveillance systems (i.e., reductions to the risk of infection) should be reviewed and system objectives re-aligned as required. Periodic review of surveillance methods should be incorporated as part of regular Infection Control Committee meetings.
Case finding via computer algorithm may result in more time saving for ICPs to be devoted to prevention, for example, using a computer-generated report to limit the number of cases that would be followed by an ICP to those with a high likelihood of infection.
Electronic systems are used to store and analyze data, HAI rates can be calculated with a greater ease and efficiency and are less prone to error, provided that the ICP has received training in the use of such programs. The system is used to define the magnitude and scope of HAIs in the country and to allow HAI rates interhospital comparison.
