VICNISS Surveillance Activities in our Hospitals

Type 1 Surveillance | Type 2 Surveillance | Post Dicharge Surveillance

Please Note: Click here for Type 1 participating hospitals and here for Type 2 participating hospitals

As a result of the work previously undertaken by the VICNISS Coordinating Centre, VICNISS surveillance is now well established in 98% of all public acute hospitals in Victoria and has been rolled out to 9 private hospitals. The challenge for the future of VICNISS surveillance will be to continue to evolve the system to meet all key stakeholders needs. Outlined below are the two types of surveillance activities that VICNISS currently offers, together with details of future directions of each of the Type 1 (for larger hospitals >100 beds) and 2 (for smaller hospitals <100 beds) programs.

TYPE 1 SURVEILLANCE

Type 1 Surveillance is based on the traditional US NHSN surveillance system. Four Surveillance Modules, have been introduced with the VICNISS program. Each surveillance module is a self-contained protocol that focuses on a particular high-risk patient group. Substantial information is collected in these modules on both infected and non-infected patients, allowing the hospitals and the VICNISS Coordinating Centre to calculate infection rates.

Type 1 Surveillance Modules

A - Surgical Site Infection (SSI) Surveillance

Hospitals are encouraged to undertake surveillance on two or more VICNISS Surgical procedures.
It is recommended that surgical procedures selected have a minimum of approximately 100 of each procedure per annum.

B - Intensive Care Unit Surveillance (ICU) Surveillance

Hospitals with an ICU should undertake surveillance on:

Central line associated bloodstream infections (CLABSIs).
Ventilator associated pneumonia (VAP).

C - Neonatal Intensive Care Unit (NNL) Surveillance

Hospitals with a neonatal intensive care unit (NICU) should undertake surveillance on:

Central line associated bloodstream infections (CLABSI).
Peripheral line associated bloodstream infections (PLABSI).

D - Haemodialysis Incident (HD)

Outpatient Haemodialysis Centres attached or affiliated with a hospital (hub or satellite) are encouraged to undertake surveillance on hospitalisations, in unit (outpatient) IV antibiotic starts, and positive blood cultures

Each hospital is able to choose which surveillance activity it undertakes, taking into consideration the infection control key performance indicators in the Statement of Priorities (agreement between the Health Minister and hospital boards on key deliverables); the strategic plan of the Infection Control program at each hospital, number of procedures and Infection Control resources. It is recommended that all surveillance activities are conducted prospectively.

Development of the VICNISS Type 1 Program

Type 1 surveillance was implemented in three phases. Ten hospitals were initially recruited by the Coordinating Centre to commence Phase I in November 2002. Phase I was used to identify any issues and implement modification to the system prior to roll out to other hospitals. Following the implementation of Phase I, surveillance was then rolled out in Phases II and III over nine months to the remaining large hospitals.

A - Surgical Site Infections

All hospitals with >100 beds contribute data on the SSI component. Data from eighteen procedure groups on over 80,000 targeted surgical procedures has been submitted. Data from the SSI component has been well accepted as has the use of the NHSN Risk Index to stratify infection rates allowing for appropriate comparison. Hospitals undertaking procedures associated with highest morbidity and mortality such as coronary artery bypass grafts (CABGS), and hip and knee arthroplasty contribute large amounts of data to VICNISS. Differences in hospital rates when compared to the aggregate have resulted in many hospitals reviewing their own practices in relation to the management of surgical patients for specific procedures.

B - Infections Acquired in Intensive Care Unit (ICU)

For adult ICU surveillance, the VICNISS program initially simplified the NHSN ICU surveillance methods, which traditionally have reported ICU acquired infections at all infection sites. VICNISS hospitals are requested only to report rates of CLABSI (laboratory confirmed) and VAP rates per 1000 days of device use. These two infection sites are those most important in terms of associated morbidity, cost and generation of antibiotic use and are reported by NHSN.

Following participant feedback and a revisions to the NHSN surveillance manual further changes have been made to the ICU surveillance module. These changes have included: patients no longer monitored for VAP after discharge from ICU; and removal of criterion 2b (a common skin contaminant is cultured from at least one blood culture and the physician institutes appropriate antimicrobial therapy) from CLABSI surveillance.

C - Infections Acquired in Neonatal Intensive Care Unit (NICU)

NICU surveillance methods were also modified after discussions with a committee of senior local neonatalogists. Concerns were expressed over the diagnosis of VAP in this patient group, as other pulmonary conditions may be clinically difficult to separate from pneumonia. The neonatalogists requested, that there be consideration for surveillance of antibiotic usage in these patients instead of undertaking VAP surveillance. This will be considered in future program developments. Data on peripheral line associated BSIs are collected, as the neonatalogists expressed concern that many neonates have peripheral lines insitu and requested related BSIs be monitored.

D - Surgical Antibiotic Prophylaxis

A major initiative during 2004, was the reporting of data on surgical antibiotic prophylaxis submitted to VICNISS over a twenty month period. Surgical antibiotic prophylaxis has been shown to be effective in reducing the incidence of surgical wound infections for many types of surgery. The measurement of compliance of surgical antibiotic prophylaxis against recommended guidelines is a common process measurement in many surveillance programs worldwide.

This report presents Statewide data assessing compliance with current recommendations for antibiotic prophylaxis in Victorian public hospitals with greater than 100 beds. Reporting to individual hospitals on compliance with published recommendations for surgical antibiotic prophylaxis is now well established. Regular reporting on antibiotic prophylaxis as part of the Statewide surveillance program and the ability for hospitals to be able to compare their performance with Statewide data has resulted in some improvements in documentation, and most importantly, compliance with guidelines, promoting optimal use of antibiotics.

E - Haemodialysis Incidents

Haemodialysis Surveillance based on the NHSN system was introduced by VICNISS in July 2008. It includes outpatients who are treated in an outpatient haemodialysis centre that is attached to or affiliated with a hospital (hub or satellite).

Haemodialysis (HD) patients require vascular access, which can either be a large blood vessel or catheter that can be repeatedly punctured to remove and replace blood. Bacteremias and localised infections of the vascular access site are common in haemodialysis patients.Because of frequent hospitalisations and receipt of antimicrobial drugs, haemodialysis patients are also at high risk for infection with drug-resistant bacteria.

International studies have reported a decrease in local vascular access infections and access-associated bacteraemias following the introduction of a surveillance program based on NHSN standardised methods and definitions.

TYPE 2 SURVEILLANCE

Type 2 surveillance methods are the methods used for smaller (<100 acute bed) Victorian public hospitals.

Most hospital acquired infection surveillance in large hospitals performing high volumes of surgery and with ICUs is directed at producing risk adjusted infection rates. These can be compared with aggregate rates compiled from Statewide data. This type of surveillance is not appropriate for many smaller hospitals, as the numbers of infections and patients at risk of infection are too small to calculate valid and reliable infection rates.

Appropriate surveillance programs for small hospitals are not well documented in the international literature. In many ways Australia is in a unique situation with respect to the numbers of smaller rural hospitals serving the population.

The approach being used by VICNISS is that surveillance of surgical patients and calculation of infection rates is only recommended for hospitals with sufficient surgical throughput. Alternative methods are more appropriate for most smaller hospitals, such as “process” surveillance and reporting of selected infections.

A - Process Indicator Surveillance

An alternative to infection (or outcome) surveillance is “process” surveillance, which aims to monitor processes that have been demonstrated to affect outcomes, rather than the outcomes (infections) themselves.

The most effective surveillance activities monitor processes that have been shown to be most closely associated with the outcome. For example, correct administration of prophylactic antibiotics to surgical patients has been shown to be effective in reducing the rate of SSIs. Therefore, for hospitals performing low volumes of surgery, it may be more appropriate to monitor the administration of prophylactic antibiotics, a frequent event, than to calculate an infection rate, which is based on much lower numbers of events/infections.

Other processes that have been demonstrated to be closely related to infection outcomes include handwashing, catheter insertion techniques and staff vaccination programs for influenza and Measles vaccination of healthcare workers.

B - Surgical Site Infection Rates

This surveillance, used in Type 1 hospitals, is suitable for some Type 2 hospitals. Data are collected on all patients undergoing certain types of surgery and these patients are monitored for infection following surgery. Risk adjustment is identical to that used in Type 1. Caution must be exercised when interpreting rates based on small numbers of patients as a single infection can cause a potentially misleading increase in the infection rate.

C - Reporting of Selected Infections and Related Events

Other approaches used include reporting of events such as multi-resistant organisms (MROs), serious wound infections and BSIs. In some cases these can be used to calculate a rate of infections using occupied bed days or another similar broad measure of throughput as a denominator. This can be useful in identifying clusters of these events at a single hospital or at a particular group of hospitals.

Type 2 Surveillance Modules

Module	Aim
Surgical Antibiotic Prophylaxis	To improve the selection, timing and duration of prophylactic antibiotics used to prevent infections at the surgical site.
Health Care Workers and Measles Vaccination	To assess Victorian public hospitals policy compliance with the National Health, Medical and Research Council (NHMRC) and Department of Human Services (DHS) recommendations for susceptible health care workers specifically in regard to Measles-Mumps-Rubella (MMR) vaccination. To determine current status of Health care workers susceptible to measles.
Health Care Workers and Hepatitis B Vaccination	To assess Victorian public hospitals policy compliance with National Health, Medical and Research Council (NHMRC) recommendations. To identify uptake of Hepatitis B vaccine offered to at risk health care workers.
Peripheral Venous Catheter (PVC) Use	To optimise the safety associated with the use of Peripheral Venous Catheters (PVCs).Short term PVCs are inserted in peripheral veins for vascular access. Although the incidence of local or bloodstream infections (BSIs) associated with PVCs is usually low, serious infectious complications may result in considerable annual morbidity.
Multi-resistant Organism (MRO)	To provide a method for individual hospitals to measure infections caused by MRSA or VRE
Primary Laboratory Confirmed Bloodstream Infection (LC-BSI)	To provide a method for individual hospitals to measure primary laboratory confirmed bloodstream infections (LC-BSIs).
Outpatient Haemodialysis Centre	To provide a method for individual outpatient haemodialysis centres to monitor bloodstream and vascular access infections and IV Vancomycin use.
Occupational Exposure	To provide a method for individual hospitals to measure reported occupational exposures.
Surgical Site Infection	To provide a method for hospitals to monitor targeted surgical procedures.
Surgical Infection Report	To ensure certain significant but infrequent deep and organ space infections are counted. The following infections are to be recorded: Deep SSI. Organ space SSI.

Type 2 surveillance activities were rolled out to 89 hospitals in the first half of 2004, following a pilot program in 14 hospitals.

By July 2004, every Victorian public hospital was contributing data to the VICNISS program.

The Type 2 program has been warmly received by the participating sites. Feedback has indicated that the Process Indicator Surveillance modules have been most useful in helping hospitals identifying deficits in existing Infection Control processes.

There has been considerable interest in the success of the Type 2 program, both at a national and international level. Recently the development of the VICNISS Type 2 program was presented at an international Infection Control conference in Los Angeles.

Post Discharge Surveillance

Infections included in the calculation of VICNISS rates include only those diagnosed during hospital admission or a subsequent re-admission for the infection. VICNISS does not include post discharge surveillance, as no simple reliable method of identifying infections after discharge has been developed. As not all hospital acquired infections are likely to be identified without rigorous post discharge surveillance, the rates reported here are an underestimate of the true rate of infection. Some studies have reported up to a 50% increase in infection rates when post discharge surveillance is conducted. However the more serious infections that occur after discharge lead to patient readmission, and will be captured by the VICNISS methods.