1、Targeted Surveillance for Nosocomial InfectionsBarbara M. Soule, RN, MPA, CICChinese Society for Nosocomial InfectionsJuly 4-5, 2004 Suzhou, China2IC Practitioner (ICP) ActivitiesConsultation3Surveillance has an Epidemiologic foundationStudy the distribution of problems and events within a defined (
2、targeted) population at risk for developing specific infections in order to plan & implement interventions.43 Key Surveillance Methods Hospital-wide Traditional SurveillanceAll infections complete- time consumingLimits time for interventions Periodic SurveillanceSelected infections or populations pe
3、riodically over timeMiss some infections Targeted Surveillance5Advantages/DisadvantagesAdapted from Pottinger et al & Gaynes et al.Targeted Surveillance7CDCs National Nosocomial Infections Surveillance (NNIS) System Targets:NNIS SystemAURICUHRNSurgicalPatientAntimicrobialUse and ResistanceIntensive
4、CareUnit(Adult/Pediatric)High Risk Nursery (NICU)Risk adjustedSSIs byProcedures8Your Hospital Surveillance System Targets:Your HospitalVAPICUBSISSIVentilator-Associated PneumoniaMedical /Surgical ICUsIntensive CareUnit(Pediatric)Primary BloodStream InfectionsPrimary OrthopedicNeurosurgical or CABGPr
5、ocedures9Which infection to target? Focus on patients at high risk for HAI Patient care areas ICUs, cardio-thoracic surgery, cancer ward Specific populations neonates, transplant patients, hemodialysis pts Procedures / Devices CT surgery, central vascular lines, ventilators Organisms of epidemiologi
6、c importance MRSA, VRSA10Targeted Surveillance forOutcomes Primary Bloodstream infections Ventilator-associated pneumonia, Surgical site infections MRSA, VRE infections Vascular access infections in hemodialysis patients Sharps injuries in healthcare providers.11Targeted Surveillance for Processes H
7、epatitis B immunity rates in personnel Personnel compliance with protocols - isolation precautions, Sterilization quality assurance testing, Effective environmental cleaning Antimicrobial prescribing and administration12How to implement targeted surveillance13Step One ICP and MD review Microbiology
8、reports daily Review past surveillance data periodically Develop a list of the potential infections or populations for targeted surveillance 14Step TwoInfection control team selects nosocomial infections to target based on one or more of the following criteria:15Criteria for Selecting Processes or O
9、utcomes for Targeted SurveillanceIC program objectivesFrequency or level of risk of infectious complications for areapatient population procedure service Morbidity, Mortality, CostPossibility for prevention16Step ThreeICP performs chart reviews on the infection-related processes or outcomes identifi
10、ed in Step Two using standardized, consistent, approved definitions. Consistent intensity and thoroughness of surveillance over time Same definitions over time17Targeted Surveillance: A Means to an End Collect only necessary data Arrive at meaningful information18So You Can: Develop meaningful inter
11、ventions DO something to reduce infections Improve patient care!19The Cycle for Success Through Targeted Surveillance1. Is there an important problem? What, why? Multidisciplinary Teams 2. Describe and understand the problem? Targeted Surveillance 3. How to affect change?Multidisciplinary TeamsEduca
12、tionFeedbackNew protocolsNew products4. Do the changes work? Remeasure Adapted from: Richards C, et al. Emerg Infect Dis 200120NLMIgnaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis21Targeted Surveillance for a ProcessTiming of Antibiotic Prophylaxis for Surgical Site Infecti
13、onNLM Archives221. Is There an Important Problem? Inappropriate surgical prophylaxis is a major infection risk exposes patient to unnecessary toxicity increases antimicrobial resistance excess doses or inappropriate spectrum antibiotics do not reduce the incidence of surgical wound infection23“Ideal
14、” Prophylaxis Ideal antibiotic for prophylaxis active against pathogens most likely to contaminate wound adequate concentrations during potential contamination administered for a short time to reduce complications, resistance, and cost24Targeted Process SurveillanceTiming of Perioperative Antimicrob
15、ial Prophylaxis012345622112345678910 10# SSIs / 100 proceduresClassen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281IncisionHours beforeincisionHours afterincisionAntibioticAdministered25Timing ofPerioperative A
16、ntimicrobial ProphylaxisTime of administration in relation to the incision # of Patients (%) Relative Risk of Infection 2-24 hours before 369 (13.0) 6.7 (2.9-14.7) 0-2 hours before 1708 (60.0) 1.0 0-3 hours after 282 (9.9) 2.4 (0.9-7.9) 3 hours after 488 (17.1) 5.8 (2.6-12.3) All 2847 (100) Classen
17、DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281262. Perform Targeted Surveillance for This Problem1) Proportion of patients who receive prophylactic antibiotics within 1 hour before surgical incision # antibiotic
18、s 1 hour # surgeries with antibiotics27Perform Targeted Surveillance for This Problem2) Proportion of patients whose antibiotics were discontinued within 24 hours of the surgery end time# discontinue w/I 24 hours # surgeries receiving antibiotics28Possible Surgical Procedures to Determine Timing of
19、Antibiotic Prophylaxis CABG Colon surgery Hip and knee arthroplasty Abdominal and vaginal hysterectomy Vascular surgery (e.g., peripheral vascular surgery)293. To Affect Change Multidisciplinary Team to look at antibiotic delivery system: current and desired Redesign system for timely AB delivery Ma
20、ke antibiotic accessible Educate nursing and operating room staff and anesthesiologists and surgeons Record time on patient chart304. Do the changes work? Re-measure 2 variables in 3 months after initiation of new improved procedure Measure surgical site infection rates.31Targeted Surveillance for a
21、n InfectionOutcome32Targeted Surveillance for OutcomesNI Rate:VAPCR-BSIUTIFoley relatedNon-Foley relatedDrives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care, d/c programPeri-care / hydration 331. Is There an Important Problem? Ventilator - associated pneumonia is a major infection
22、 risk for patients increased mortality excess length of stay excess cost34Example: Challenge for Targeted Surveillance Reduce ventilator associated pneumonias (targeted adverse event) by 50% # VAP infections # 1000 ventilator days35Reduction of VAP with Targeted Surveillance and InterventionsUnit199
23、71998ReductionSICU45.1/1000VD27.9 /1000VD17.2 /1000 VDMICU22.4 /1000VD11.6 /1000 VD10.8 /1000 VDKwan KL, Baker SP, Fontecabio SA. Impact of a program ofintensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia, and its cost effectivene
24、ssICHE 2003;24;11:859-63.36Reduction of VAP with Targeted Surveillance and Interventions Inverventions: Raise head of bed Sterile water for tube feedings In-line suction catheters from 24 - 48 -72- as needed Cost savings $350,000 in one year.371. Is There an Important Problem? Catheter-related blood
25、stream infections are a serious infection risk device-related morbidity and mortality extra length of stay additional medical costs380510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98 - MarchSICU BSI Jan 98 - March 00Rate per 1,000 line daysRate per 1,000 line daysExample: Challenge fo
26、r Targeted Surveillance392. Perform Targeted Surveillance for This ProblemMonitor blood streaminfections in Surgical ICUpatients.403. Affect ChangeSuccessful interventions from targeted surveillance for BSI 1. Successful education program to reduce catheter associated blood stream infections2. Drape
27、s and full PPE during insertion3. Monitoring and care for site414. Do the changes work? Re-measure in 3 months after initiation of new improved procedure Measure bloodstream infection rates.420510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98 - MarchSICU BSI Jan 98 - March 00BSIBSIInterventionInterventionsRate per 1,000 line daysRate per 1,000 line daysExample: Challenge for Targeted Surveillance43With targeted surveillance
