Methodologies used in surveillance of surgical wound infections and bacteremia in Australian hospitals

Differences in identifying healthcare associated infections using clinical vignettes and the influence of respondent characteristics: a cross-sectional survey of Australian infection prevention staff

Background

Australia has commenced public reporting and benchmarking of healthcare associated infections (HAIs), despite not having a standardised national HAI surveillance program. Annual hospital Staphylococcus aureus bloodstream (SAB) infection rates are released online, with other HAIs likely to be reported in the future. Although there are known differences between hospitals in Australian HAI surveillance programs, the effect of these differences on reported HAI rates is not known.

Objective

To measure the agreement in HAI identification, classification, and calculation of HAI rates, and investigate the influence of differences amongst those undertaking surveillance on these outcomes.

Methods

A cross-sectional online survey exploring HAI surveillance practices was administered to infection prevention nurses who undertake HAI surveillance. Seven clinical vignettes describing HAI scenarios were included to measure agreement in HAI identification, classification, and calculation of HAI rates. Data on characteristics of respondents was also collected. Three of the vignettes were related to surgical site infection and four to bloodstream infection. Agreement levels for each of the vignettes were calculated. Using the Australian SAB definition, and the National Health and Safety Network definitions for other HAIs, we looked for an association between the proportion of correct answers and the respondents’ characteristics.

Results

Ninety-two infection prevention nurses responded to the vignettes. One vignette demonstrated 100 % agreement from responders, whilst agreement for the other vignettes varied from 53 to 75 %. Working in a hospital with more than 400 beds, working in a team, and State or Territory was associated with a correct response for two of the vignettes. Those trained in surveillance were more commonly associated with a correct response, whilst those working part-time were less likely to respond correctly.

Conclusion

These findings reveal the need for further HAI surveillance support for those working part-time and in smaller facilities. It also confirms the need to improve uniformity of HAI surveillance across Australian hospitals, and raises questions on the validity of the current comparing of national HAI SAB rates.

Variation in health care-associated infection surveillance practices in Australia

In the absence of a national health care-associated infection surveillance program in Australia, differences between existing state-based programs were explored using an online survey. Only 51% of respondents who undertake surveillance have been trained, fewer than half perform surgical site infection surveillance prospectively, and only 41% indicated they risk adjust surgical site infection data. Widespread variation of surveillance methods highlights future challenges when considering the development and implementation of a national program in Australia.

Preventing Central Venous Catheter-Associated Primary Bloodstream Infections: Characteristics of Practices Among Hospitals Participating in the Evaluation of Processes and Indicators in Infection Control (EPIC) Study

Objectives:

To describe the conceptual framework and methodology of the Evaluation of Processes and Indicators in Infection Control (EPIC) study and present results of CVC insertion characteristics and organizational practices for preventing BSIs. The goal of the EPIC study was to evaluate relationships among processes of care, organizational characteristics, and the outcome of BSI.

Design:

This was a multicenter prospective observational study of variation in hospital practices related to preventing CVC-associated BSIs. Process of care information (eg, barrier use during insertions and experience of the inserting practitioner) was collected for a random sample of approximately 5 CVC insertions per month per hospital during November 1998 to December 1999. Organization demographic and practice information (eg, surveillance activities and staff and ICU nurse staffing levels) was also collected.

Setting:

Medical, surgical, or medical-surgical ICUs from 55 hospitals (41 U.S. and 14 international sites).

Participants:

Process information was obtained for 3,320 CVC insertions with an average of 58.2 (± 16.1) insertions per hospital. Fifty-four hospitals provided policy and practice information.

Results:

Staff spent an average of 13 hours per week in study ICU surveillance. Most patients received nontunneled, multiple lumen CVCs, of which fewer than 25% were coated with antimicrobial material. Regarding barriers, most clinicians wore masks (81.5%) and gowns (76.8%); 58.1% used large drapes. Few hospitals (18.1%) used an intravenous team to manage ICU CVCs.

Conclusions:

Substantial variation exists in CVC insertion practice and BSI prevention activities. Understanding which practices have the greatest impact on BSI rates can help hospitals better target improvement interventions.

Impact of revising the National Nosocomial Infection Surveillance System definition for catheter-related bloodstream infection in ICU: reproducibility of the National Healthcare Safety Network case definition in an Australian cohort of infection control professionals

BACKGROUND

Effective and comparable surveillance for central venous catheter-related bloodstream infections (CLABSIs) in the intensive care unit requires a reproducible case definition that can be readily applied by infection control professionals.

METHODS

Using a questionnaire containing clinical cases, reproducibility of the National Nosocomial Infection Surveillance System (NNIS) surveillance definition for CLABSI was assessed in an Australian cohort of infection control professionals participating in the Victorian Hospital Acquired Infection Surveillance System (VICNISS). The same questionnaire was then used to evaluate the reproducibility of the National Healthcare Safety Network (NHSN) surveillance definition for CLABSI. Target hospitals were defined as large metropolitan (1A) or other large hospitals (non-1A), according to the Victorian Department of Human Services. Questionnaire responses of Centers for Disease Control and Prevention NHSN surveillance experts were used as gold standard comparator.

RESULTS

Eighteen of 21 eligible VICNISS centers participated in the survey. Overall concordance with the gold standard was 57.1%, and agreement was highest for 1A hospitals (60.6%). The proportion of congruently classified cases varied according to NNIS criteria: criterion 1 (recognized pathogen), 52.8%; criterion 2a (skin contaminant in 2 or more blood cultures), 83.3%; criterion 2b (skin contaminant in 1 blood culture and appropriate antimicrobial therapy instituted), 58.3%; non-CLABSI cases, 51.4%. When survey questions regarding identification of cases of CLABSI criterion 2b were removed (consistent with the current NHSN definition), overall percentage concordance increased to 62.5% (72.2% for 1A centers).

CONCLUSION

Further educational interventions are required to improve the discrimination of primary and secondary causes of bloodstream infection in Victorian intensive care units. Although reproducibility of the CLABSI case definition is relatively poor, adoption of the revised NHSN definition for CLABSI is likely to improve the concordance of Victorian data with international centers.

Assessing the status of infection control programs in small rural hospitals in the western United States

BACKGROUND

Organized infection control (IC) interventions have been successful in reducing the acquisition of hospital-associated infections. Rural community hospitals, although contributing significantly to the US health care system, have rarely been assessed regarding the nature and quality of their IC programs.

METHODS

A sample of 77 small rural hospitals in Idaho, Nevada, Utah, and eastern Washington completed a written survey in 2000 regarding IC staffing, infrastructure support, surveillance of nosocomial infections, and IC policies and practices.

RESULTS

Almost all hospitals (65 of 67, 97%) had one infection control practitioner (ICP), and 29 of 61 hospitals (47.5%) reported a designated physician with IC oversight. Most ICPs (62 of 64, 96.9%) were also employed for other activities outside of IC. The median number of ICP hours per week for IC activities was 10 (1-40), equating to a median of 1.56 (0.30-21.9) full-time ICPs per 250 hospital beds. Most hospitals performed total house surveillance for nosocomial infections (66 of 73, 90.4%) utilizing Centers for Disease Control and Prevention (CDC) definitions (69 of 74, 93.2%). Most also monitored employee bloodborne exposures (69 of 73, 94.5%). All hospitals had a written bloodborne pathogen exposure plan and isolation policies. CDC guidelines were typically followed when developing IC policies. Access to medical literature and online resources appeared to be limited for many ICPs.

CONCLUSIONS

Most rural hospitals surveyed have expended reasonable resources to develop IC programs that are patterned after those seen in larger hospitals and conform to recommendations of consensus expert panels. Given these hospitals' small patient census, short length of stay, and low infection rates, further studies are needed to evaluate necessary components of effective IC programs in these settings that efficiently utilize limited resources without compromising patient care.

Hospital infection control in Australia

Australia is a large country divided into six states and two territories, each of which has infection control programmes. This paper looks at the organization of infection control in Australia, as well as describing the national bodies involved and recent state initiatives in infection control.

A comparison of two methods for identifying surgical site infections following orthopaedic surgery

Many infection control practitioners (ICPs) dedicate a significant amount of time and resources to surveillance of surgical site infections (SSIs). Alternative surveillance methods need to be explored to reflect the changes to the healthcare system and the increasing economic constraints placed on infection control units. This study was undertaken to compare two methods of identifying SSIs in orthopaedic surgery. Surveillance data collected routinely by ICPs was compared with data obtained from the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) coding in the medical record. Concordant results between the two methods were obtained. The use of ICD-9-CM coding, as stored in hospital patient administration system databases, has the ability to enhance routine surgical site surveillance programmes. These systems can be used as the basis for screening large data sets for SSIs and identifying where SSIs resulted in patient re-admission. A reduction in the duplication of data and time spent by the ICP on the collection of information for surveillance purposes can be achieved.

Variation in administrators' and clinicians' attitudes toward critical elements of an infection control program and the role of the infection control practitioner in New South Wales, Australia

BACKGROUND

Debate remains over the core activities of infection control (IC) programs. Differences in stakeholder opinions must be considered if consensus panel guidelines and recommendations are to be broadly applied. This article describes a survey of administrators and clinicians employed in hospitals in New South Wales, Australia. Respondents self-reported their levels of agreement with affirmative statements regarding the role of the infection control practitioner (ICP) and the essential requirements and infrastructure of IC programs.

METHOD

The study population included administrators and clinicians in each public, private, and freestanding day hospital in New South Wales. Respondents reported the intensity of their agreement with 16 affirmative statements relating to IC program infrastructure and resources and the ICP's role and responsibilities.

RESULTS

The overall response rate was 62.1% (587/945). Clinicians (349/587) and administrators (238/587) accounted for 59.5% and 40.5% of the response rate, respectively. Overall, administrators and clinicians reported greatest levels of agreement for those elements not requiring additional resources.

CONCLUSION

The extent of divergence between administrators and clinicians is not so great that it can not be resolved. Our findings demonstrate the degree of administrator support that clinicians can expect for each element. We advocate better communication between clinicians and administrators in conjunction with objective strategic planning. Our findings provide a guide for ICPs to either establish or negotiate the core components of their IC program.

Pilot testing standardized surveillance: Hospital Infection Standardised Surveillance (HISS). On behalf of the HISS Reference Group

In Australia the time-consuming nature of double handling of surveillance data has meant that surveillance methodology rarely included prospective monitoring of patients at risk for the acquisition of a nosocomial infection. To streamline surveillance activities, infection control professionals favored the collection of case data either from the ward or pathology laboratories. By default, this method introduced a variety of definitions resulting in inconsistencies across health care facilities and artificial fluctuations in the magnitude of infection. In June 1998, the New South Wales Health Department funded its first attempt to develop and implement a standardized approach to collection of nosocomial infection data-Hospital Infection Standardized Surveillance (HISS). Six months later, in December 1998, 10 public acute care hospitals pilot tested the content and methodology of HISS. HISS members tested the application of the National Nosocomial Infection Surveillance system definitions for infection, active and passive surveillance methodology, the handheld computer for data collection, and the Electronic Infection Control Automated Technology (eICAT) version for HISS software and analysis. HISS member hospitals selected from several sentinel monitoring programs such as intravascular device-related bacteremia and nonintravascular device-related bacteremia infections, surgical site infections, respiratory syncytial virus infections, and rotavirus infections. Hospitals continued to perform active surveillance in the first 12 months, collecting demographic variables, risk factors, and outcomes. The completeness of the data sets for the two most frequently monitored programs, surgical site infections and intravascular device-related bacteremia, was high, with 99.6% of the required 36, 372 surgical site infection data fields and 99.4% of the 572,717 intravascular device-related bacteremia data fields completed.