1、Targeted Surveillance for Nosocomial InfectionsBarbara M.Soule,RN,MPA,CICChinese Society for Nosocomial InfectionsJuly 4-5,2004 Suzhou,China1IC Practitioner(ICP)ActivitiesConsultation2Surveillance has an Epidemiologic foundationStudy the distribution of problems and events within a defined (targeted
2、)population at risk for developing specific infections in order to plan&implement interventions.33 Key Surveillance Methods Hospital-wide Traditional SurveillanceAll infections complete-time consumingLimits time for interventions Periodic SurveillanceSelected infections or populations periodically o
3、ver timeMiss some infections Targeted Surveillance4Advantages/DisadvantagesAdapted from Pottinger et al&Gaynes et al.5Targeted Surveillance6CDCs National Nosocomial Infections Surveillance(NNIS)System Targets:NNIS SystemAURICUHRNSurgicalPatientAntimicrobialUse and ResistanceIntensive CareUnit(Adult/
4、Pediatric)High Risk Nursery(NICU)Risk adjustedSSIs byProcedures7Your Hospital Surveillance System Targets:Your HospitalVAPICUBSISSIVentilator-Associated PneumoniaMedical/Surgical ICUsIntensive CareUnit(Pediatric)Primary BloodStream InfectionsPrimary OrthopedicNeurosurgical or CABGProcedures8Which in
5、fection 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 epidemiologic importance MRSA,VRSA9Tar
6、geted 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.10Targeted Surveillance for Processes Hepatitis B immunity rates in p
7、ersonnel Personnel compliance with protocols-isolation precautions,Sterilization quality assurance testing,Effective environmental cleaning Antimicrobial prescribing and administration11How to implement targeted surveillance12Step One ICP and MD review Microbiology reports daily Review past surveill
8、ance data periodically Develop a list of the potential infections or populations for targeted surveillance 13Step TwoInfection control team selects nosocomial infections to target based on one or more of the following criteria:14Criteria for Selecting Processes or Outcomes for Targeted SurveillanceI
9、C program objectivesFrequency or level of risk of infectious complications for areapatient population procedure service Morbidity,Mortality,CostPossibility for prevention15Step ThreeICP performs chart reviews on the infection-related processes or outcomes identified in Step Two using standardized,co
10、nsistent,approved definitions.Consistent intensity and thoroughness of surveillance over time Same definitions over time16Targeted Surveillance:A Means to an End Collect only necessary data Arrive at meaningful information17So You Can:Develop meaningful interventions DO something to reduce infection
11、s Improve patient care!18The Cycle for Success Through Targeted Surveillance1.Is there an important problem?2.3.What,why?4.Multidisciplinary Teams 2.Describe and understand the problem?Targeted Surveillance 3.How to affect change?Multidisciplinary TeamsEducationFeedbackNew protocolsNew products4.Do
12、the changes work?Remeasure Adapted from:Richards C,et al.Emerg Infect Dis 200119NLMIgnaz Semmelweis Targeted Surveillance And InterventionFor Puerperal Sepsis20Targeted Surveillance for a ProcessTiming of Antibiotic Prophylaxis for Surgical Site InfectionNLM Archives211.Is There an Important Problem
13、?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 infection22“Ideal”Prophylaxis Ideal antibiotic for prophylaxis act
14、ive against pathogens most likely to contaminate wound adequate concentrations during potential contamination administered for a short time to reduce complications,resistance,and cost23Targeted Process SurveillanceTiming of Perioperative Antimicrobial Prophylaxis012345622112345678910 10#SSIs/100 pro
15、ceduresClassen 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 afterincisionAntibioticAdministered24Timing ofPerioperative Antimicrobial ProphylaxisTime of administration in relation
16、 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 DC,et al.The timing of prophylactic administration of antibiotics and the ris
17、k of surgical-wound infection.N Engl J Med 1992;326:281252.Perform Targeted Surveillance for This Problem1)Proportion of patients who receive prophylactic antibiotics within 1 hour before surgical incision#antibiotics 1 hour#surgeries with antibiotics26Perform Targeted Surveillance for This Problem2
18、)Proportion of patients whose antibiotics were discontinued within 24 hours of the surgery end time#discontinue w/I 24 hours#surgeries receiving antibiotics27Possible Surgical Procedures to Determine Timing of Antibiotic Prophylaxis CABG Colon surgery Hip and knee arthroplasty Abdominal and vaginal
19、hysterectomy Vascular surgery(e.g.,peripheral vascular surgery)283.To Affect Change Multidisciplinary Team to look at antibiotic delivery system:current and desired Redesign system for timely AB delivery Make antibiotic accessible Educate nursing and operating room staff and anesthesiologists and su
20、rgeons Record time on patient chart294.Do the changes work?Re-measure 2 variables in 3 months after initiation of new improved procedure Measure surgical site infection rates.30Targeted Surveillance for an InfectionOutcome31Targeted Surveillance for OutcomesNI Rate:VAPCR-BSIUTIFoley relatedNon-Foley
21、 relatedDrives Intervention For:Pneumonia preventionCR-BSI preventionFoley-care,d/c programPeri-care/hydration 321.Is There an Important Problem?Ventilator-associated pneumonia is a major infection risk for patients increased mortality excess length of stay excess cost33Example:Challenge for Targete
22、d Surveillance Reduce ventilator associated pneumonias(targeted adverse event)by 50%#VAP infections#1000 ventilator days34Reduction of VAP with Targeted Surveillance and InterventionsUnit19971998ReductionSICU45.1/1000VD27.9/1000VD17.2/1000 VDMICU22.4/1000VD11.6/1000 VD10.8/1000 VDKwan KL,Baker SP,Fo
23、ntecabio SA.Impact of a program ofintensive surveillance and interventions targeting ventilated patients in the reduction of ventilator-associated pneumonia,and its cost effectivenessICHE 2003;24;11:859-63.35Reduction of VAP with Targeted Surveillance and Interventions Inverventions:Raise head of be
24、d Sterile water for tube feedings In-line suction catheters from 24-48-72-as needed Cost savings$350,000 in one year.361.Is There an Important Problem?Catheter-related bloodstream infections are a serious infection risk device-related morbidity and mortality extra length of stay additional medical c
25、osts370510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98-MarchSICU BSI Jan 98-March 00Rate per 1,000 line daysRate per 1,000 line daysExample:Challenge for Targeted Surveillance382.Perform Targeted Surveillance for This ProblemMonitor blood streaminfections in Surgical ICUpatients.393.
26、Affect ChangeSuccessful interventions from targeted surveillance for BSI 1.Successful education program to reduce catheter associated blood stream infections2.Drapes and full PPE during insertion3.Monitoring and care for site404.Do the changes work?Re-measure in 3 months after initiation of new improved procedure Measure bloodstream infection rates.410510152025JanAprilJulyOctJanAprilJulyOctJan989900SICU BSI Jan 98-MarchSICU BSI Jan 98-March 00BSIBSIInterventionInterventionsRate per 1,000 line daysRate per 1,000 line daysExample:Challenge for Targeted Surveillance42With targeted surveillance43
