surveillance in infection control program2

8/6/2019 Surveillance in Infection Control Program2

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Surveillance In InfectionSurveillance In InfectionControl ProgramControl Program

ByBy

Prof.Prof. DDr. Aisha Aboul Fotouhr. Aisha Aboul FotouhFacult y of MedicineFacult y of Medicine

Ain Shams Universit y Ain Shams Universit y



Definition of SurveillanceDefinition of Surveillance

A s ystemic and ongoing method of data A s ystemic and ongoing method of data

collection, presentation and anal yzingcollection, presentation and anal yzing

then followed b y dissemination of thatthen followed b y dissemination of thatinformation to those who can improveinformation to those who can improve

the outcome.the outcome. The data concerning the The data concerning the

distribution and determinants of adistribution and determinants of agiven disease or an y health eventgiven disease or an y health event..

Prof Dr Aisha Aboul Fotouh



The Surveillance C ycle The Surveillance C ycle

Planning for def inition of objectiveEvaluation

Inter vention

Dissemination Tools of sur veillance

Analysis and interpretation

Data collection

Implementation




K e y Facts for SurveillanceK e y Facts for Surveillance

Surveillance should be constantly changing; has an evolutionary Surveillance should be constantly changing; has an evolutionary nature so infection control professionals must be adopted tonature so infection control professionals must be adopted tochange.change.

Epidemiology is a population based science, surveillance isEpidemiology is a population based science, surveillance isplanned to study the distribution and determinants withinplanned to study the distribution and determinants withindefined population who are at risk for development of specificdefined population who are at risk for development of specificoutcome.outcome.

For surveillance there is no cook book for it so it is lessFor surveillance there is no cook book for it so it is lessimportant to identify a surveillance system by a particular nameimportant to identify a surveillance system by a particular namebut is important to be well designed. So each health carebut is important to be well designed. So each health careorganization must tailor its surveillance system to maximizeorganization must tailor its surveillance system to maximizeutility of all health care resources and best match resources withutility of all health care resources and best match resources withoutcome priority to achieve institutional objective.outcome priority to achieve institutional objective.




K e y Facts for SurveillanceK e y Facts for Surveillance

On surveillance, data is tied toOn surveillance, data is tied to action dataaction data andandreports generated must support the health care teamreports generated must support the health care team¶¶sseffort in risk reduction in process and systemeffort in risk reduction in process and systemimprovement thus it is important for continuous quality improvement thus it is important for continuous quality improvement so the success of any surveillanceimprovement so the success of any surveillanceprogram must be based on improving of patient care.program must be based on improving of patient care.

Surveillance may be a monitoring process which likely Surveillance may be a monitoring process which likely

leads to outcome i.e. indwelling catheterleads to outcome i.e. indwelling catheter

Surveillance is a team approach.Surveillance is a team approach.




Usage of SurveillanceUsage of Surveillance

I.I. Improvement of outcomes and processorsImprovement of outcomes and processors

± ± Through convincing the members of health care team of the Through convincing the members of health care team of theneed to implement prevention and control activitiesneed to implement prevention and control activities

± ± Armed with expert in infection control, the surveillance data Armed with expert in infection control, the surveillance data

has influential effect on clinicianhas influential effect on clinician ± ± Through provision the providers of any service by their Through provision the providers of any service by their

outcome in comparison with other groupsoutcome in comparison with other groups

± ± Through monitoring of the quality indicators, e.g. clinical Through monitoring of the quality indicators, e.g. clinicalindicator as nosocomial infection rate by which we canindicator as nosocomial infection rate by which we can

define any weakness or areas of opportunities that may existdefine any weakness or areas of opportunities that may existin the system .in the system .

II.II. Provide base line dataProvide base line data which directly influence health care which directly influence health care personnel to search for mechanism to lower rate by personnel to search for mechanism to lower rate by

improving the process to irimproving the process to ir--reductable minimumreductable minimum ..




Usage of Surveillance (cont.)Usage of Surveillance (cont.)

III.III. Problem identificationProblem identification

-- Such as detection of unrecognized clusters or outbreak Such as detection of unrecognized clusters or outbreak

-- Sentinel event: SSI caused by group A streptococci , orSentinel event: SSI caused by group A streptococci , orexposure T.B before isolationexposure T.B before isolation ± ± exposure to AIDS beforeexposure to AIDS beforediagnosisdiagnosis

IV.IV. Evaluation of the control measures:Evaluation of the control measures:

If intervention activities has been implemented for purposeIf intervention activities has been implemented for purpose

of interrupting the transmission of any site of infection.of interrupting the transmission of any site of infection.Continued measurement is necessary to determine theContinued measurement is necessary to determine theeffectiveness of any interventioneffectiveness of any intervention





V. V. Evaluation and reinforcement of practice:Evaluation and reinforcement of practice:Surveillance evaluate the change in practice and theSurveillance evaluate the change in practice and theparallel change in infection rate and can reinforceparallel change in infection rate and can reinforce

the caregivers to the preventive practice which mustthe caregivers to the preventive practice which mustbe integrated as routine behavior e.g. recapping be integrated as routine behavior e.g. recapping prevention of the needle.prevention of the needle.

VI. VI. Education of the health care team:Education of the health care team:Educational information become more meaningfulEducational information become more meaningful when it contains locally derived data with relevance when it contains locally derived data with relevanceto practice.to practice.





VII. VII. ResearchResearch VIII. VIII. For accreditation:For accreditation: Accrediting agencies Accrediting agencies

strongly suggest presence of strongly suggest presence of surveillance activity.surveillance activity.

IX.IX. Investigation of problems:Investigation of problems: Extra effort isExtra effort is

needed to give additional information by inneeded to give additional information by in

depth surveillance.depth surveillance.

X.X. For determining outbreak threshold:For determining outbreak threshold: doubleddoubled

the baseline rate.the baseline rate.N.B Is surveillance needed in outpatient or shortN.B Is surveillance needed in outpatient or short

course setting.course setting.




Surveillance processSurveillance process

I.I. Choosing the event to be studiedChoosing the event to be studied

Choosing the problemChoosing the problem

-- Relative frequenciesRelative frequencies

-- Cost of negative outcomeCost of negative outcome

-- Potential for preventionPotential for prevention

-- Priority by health care teamPriority by health care team-- Community needsCommunity needs

-- Organizational missionOrganizational mission

-- Available resources Available resources




II.II. Defining the stud y populationDefining the stud y population

-- Ideally total populationIdeally total population

-- If defined broadly i.e. heterogeneous, the rateIf defined broadly i.e. heterogeneous, the rate

will not be able to pinpoint the preventive will not be able to pinpoint the preventive

measure.measure.

-- If narrow i.e. homogenous, it givesIf narrow i.e. homogenous, it gives

restricted results.restricted results.

Sur veillance process (cont.)Sur veillance process (cont.)Prof Dr Aisha Aboul Fotouh



III.III. Appropriate method of measurement Appropriate method of measurement

Decision about rate must be in the planning process toDecision about rate must be in the planning process todefine what t y pe of data to be collecteddefine what t y pe of data to be collected

RatioRatio = a / b= a / b

RateRate = a / a+b x K in certain time and place= a / a+b x K in certain time and place

Crude rateCrude rate: overall rate: overall rate

Categor y specificCategor y specificPrevalence rate:Prevalence rate:

No. of existing cases from specified interval or point of timeNo. of existing cases from specified interval or point of time

Population at risk in the same timePopulation at risk in the same time

Incidence rate:Incidence rate:

No. of new cases of a diseaseNo. of new cases of a disease

Population at risk in the same timePopulation at risk in the same time

Incidence densit y:Incidence densit y:

No. of cases during an observation periodNo. of cases during an observation period

Time each person was observed totaled for all patients Time each person was observed totaled for all patients

Adjusted rate Adjusted rate

Risk indexRisk index ---- StratificationStratification

x K

x K

x 100




IV.IV. Definition of numerator:Definition of numerator: We have the CDC definition We have the CDC definition

Criteria for infectionInfection site

Positive culturePositive cultureBloodBlood

>= 10 / colonies of bacteria per 1ml>= 10 / colonies of bacteria per 1mlUrineUrine

Pus at the incision sitePus at the incision sitePostoperative woundsPostoperative wounds

Presence of pusPresence of pusOther woundsOther wounds

>= 10 organisms per 1 g of biopsied tissue; new >= 10 organisms per 1 g of biopsied tissue; new

inflammation or new pus not present on admissioninflammation or new pus not present on admission

BurnsBurns

New sputum production with new infiltrate on chest XNew sputum production with new infiltrate on chest X--ra y ra y

not present on admissionnot present on admission

Pulmonar yPulmonar y

Positive culture for pathogen or unexplained diarrhea forPositive culture for pathogen or unexplained diarrhea for

>= 2 da ys>= 2 da ys

IntestinalIntestinal

Pus at sitePus at siteSkin/ IV Skin/ IV

Clinical pictureClinical pictureMiscellaneous ( hepatitis, URTI,Miscellaneous ( hepatitis, URTI,

peritonitis peritonitis ----))

5

6




V. V. Denominator:Denominator:

-- Population at risk Population at risk

-- No. of exposures i.e. No. of surgical proceduresNo. of exposures i.e. No. of surgical procedures

-- Days risk Days risk

Sur veillance process (cont.)Sur veillance process (cont.)




VI. VI. Collection of dataCollection of data

A A-- What data should be collected? What data should be collected? The value of data collected vs. burden of The value of data collected vs. burden of collection and analysiscollection and analysisdemographic, clinical, laboratory and risk demographic, clinical, laboratory and risk

factors ( host and procedures).factors ( host and procedures).

BB-- Who collects the data? Who collects the data?

-- Active vs. Passive Active vs. Passive

-- ResponsibilitiesResponsibilities-- Quality management of collected dataQuality management of collected data-- Multidisciplinary collaborationMultidisciplinary collaboration




CC-- Timing of surveillance: Timing of surveillance:

-- Concurrent or prospectiveConcurrent or prospective

-- Retrospective surveillanceRetrospective surveillance

-- Post discharge surveillancePost discharge surveillance


Prof Dr Aisha Aboul

Fotouh



DD-- T y pes of surveillance T y pes of surveillance

DisadvantageDisadvantage Advantage Advantage T y pe of surveillance T y pe of surveillance

-- Time consuming Time consuming

--Need a full time ICPNeed a full time ICP

--Collect baselineCollect baseline

-- Identif y trendIdentif y trend

--Recognize theRecognize the

outbreak outbreak

Hospital wideHospital wide

surveillancesurveillance

--Provide limited dataProvide limited data

-- Missing clustersMissing clusters

-- Measures new +oldMeasures new +old

casescases

--Eas yEas y

--Not time consumingNot time consuming

--Gives magnitude of Gives magnitude of

the problemthe problem

PeriodicPeriodic

surveillancesurveillance

(prevalence surveillance)(prevalence surveillance)

-- Data restricted onl y Data restricted onl y

to surve yed groupto surve yed group

-- For specificFor specific

objectivesobjectives

-- Concentrate to highConcentrate to high

risk area e.g. VAPrisk area e.g. VAP

-- Defined baselineDefined baseline

and thresholdand threshold

Targeted Targeted

surveillancesurveillance(for outbreak threshold)(for outbreak threshold)




EE-- Source of Data and Case Finding MethodsSource of Data and Case Finding Methods

Total char t review 0.74 - 0.94

Selected medical record

Kardex screening 0.75 - 0.94

Fever char t 0.09 - 0.56

Antibiotic 0.57

Labor ator y repor ts 0.77- 0.91

Methods Sensitivit y

Autopsy repor ts 0.08

Readmission 0.08

Risk f actor based sur veillance 0.50 ± 0.89




FF-- Data collection:Data collection:

Standardized form facilitate consistency Standardized form facilitate consistency

It must be designated with medical recordIt must be designated with medical record

to achieve surveillance objectivesto achieve surveillance objectives

-- Line listing form:Line listing form:Contains data for many patientsContains data for many patients

Gives rapid conclusion but not suitable for comprehensiveGives rapid conclusion but not suitable for comprehensivesurveillance for large populationsurveillance for large population

-- Case form:Case form:Used for single caseUsed for single case

Gives detailed data for population based surveillanceGives detailed data for population based surveillance




VII. VII. Data presentation:Data presentation:

Computer is essentialComputer is essential

-- Tabulation according to: site, pathogen, host Tabulation according to: site, pathogen, hostrelated risk factor, therapy, procedures, risk related risk factor, therapy, procedures, risk strata e.g. birth weightstrata e.g. birth weight

-- Cross tabulation: Pathogen and siteCross tabulation: Pathogen and site-- Line trendLine trend

-- Area map Area map




VIII. VIII. Evaluation and interpretation:Evaluation and interpretation:

-- Calculation of rateCalculation of rate

-- Risk stratificationRisk stratification

-- Standardized risk stratificationStandardized risk stratification

for inter hospital comparisonfor inter hospital comparison





IX.IX. Dissemination of dataDissemination of data

A A-- Feedback is an important interventionFeedback is an important intervention

BB-- Surveillance report should be behind ICCSurveillance report should be behind ICCCC-- Methods of presentation:Methods of presentation:

--Verbal or Written Verbal or Written

--Written is preferred as it is documented Written is preferred as it is documentedDD-- Effective messageEffective message

EE-- Timing of report Timing of report





X.X. Intervention and improvement activities:Intervention and improvement activities:

-- It is specially tailored for every problemIt is specially tailored for every problem

ICC is very important with stakeholders as it isICC is very important with stakeholders as it ismultidisciplinary approachmultidisciplinary approach

-- It must be documentedIt must be documented

XI.XI.Follow up and surveillance:Follow up and surveillance:

Did the rate improve after surveillance?Did the rate improve after surveillance?




Mechanism to enhance qualit y of Mechanism to enhance qualit y of

surveillance datasurveillance data1.1. Training of surveillance staff Training of surveillance staff must be standardizedmust be standardized

2.2. Qualit y controlQualit y control through external validation of through external validation of surveillance decisions is important to ensure thatsurveillance decisions is important to ensure thatdefinitions are being accurately applied to meet whatdefinitions are being accurately applied to meet whatis calledis called ³³gold standardgold standard´́ This could be done by This could be done by reviewing sample of cases.reviewing sample of cases.

3.3. Consistenc yConsistenc y of the surveillance effort andof the surveillance effort and

methodologies must be maintained over a time, sincemethodologies must be maintained over a time, sincethe intensely of surveillance will effect the sensitivity the intensely of surveillance will effect the sensitivity of the system. So it is important to avoid fluctuationof the system. So it is important to avoid fluctuationin the surveillance activity either by increase patientsin the surveillance activity either by increase patients

or decreased staffing.or decreased staffing.




Mechanism to enhance qualit y of Mechanism to enhance qualit y of

surveillance datasurveillance data44.. Administrative commitment Administrative commitment to the infectionto the infection

control program should be provided tocontrol program should be provided to

support the surveillance activities.support the surveillance activities.

55.. Computerization:Computerization: It facilitates the function of It facilitates the function of

all components of surveillance and support theall components of surveillance and support theinformation system within the hospital.information system within the hospital.




Steps in outbreak investigationsSteps in outbreak investigations

1- Review existing information

2- Determine the nature, location and

severit y of the disease problem 3- Verif y the diagnosis

4- Establish a case definition

5- Request that the laborator y saves

isolates from affected patients and from

suspected sources or vehicles




Steps in outbreak investigations (cont.)Steps in outbreak investigations (cont.)

6- Draw an epidemic curve

7- Establish the existence of an outbreak 8- Develop h y potheses

9- Test h y potheses in comparative ( case-

control or cohort) studies

10- Provide control measures




Application of surveillance for antibiotic

usageIt can solve some problems associated with antibiotic usage:

1) The usage of broad-spectrum agents when restricted

spectrum are as effective.

2) Treatment for long duration.

3) Treatment by intravenous route when oral therapy is

effective.

4) Use of combined therapy when one is effective.

5) Inappropriate dosage for patients with chronic diseases e.g.

chronic renal or hepatic dysfunction.

6) Definition of MRSA and identification of the sources of

infection specially in the presence of clusters of infection.




Through surveillance we can perform drug

utilization evaluation (DUEs)

Importance of (DUEs)

- We can identify the usage pattern and trend of

antibiotic usage in different hospital units.- Provide base line data for usage of antibiotics.

- It give feed back to Clinicians for any arising side

effect.

- Give information regarding emerging of resistantpathogens.

- Provide data for cost containment.




T

hank you

surveillance in infection control program2

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