What is Surveillance   

      

Surveillance of healthcare infections (HAIs) refers to the monitoring and reporting of these events. Surveillance of HAIs is important because of the research demonstrating that up to one-third of infections can be prevented through having infection and control surveillance programs in place (Haley et al 1985). 

Each year in Australia there are about 200,000 healthcare associated infections (Cruickshank et al 2008). This imposes a significant cost on the healthcare system, as well as significant morbidity and other costs on affected individuals. 

Surveillance of healthcare associated infection assists in identifying: 

  • Whether there is an infection problem
  • The magnitude of the problem
  • The factors that contribute to infections

Surveillance also allows hospitals and clinicians to measure the effectiveness of strategies that are implemented to decrease infection rates. Infection rate data should be used in a positive way to improve the quality and safety of healthcare. Going through the process of undertaking surveillance will not usually influence infection rates appreciably itself, unless surveillance is linked to a prevention strategy. The information must be fed back to those who need to know: infection control nurses, surgeons, intensive care clinicians and hospital management, for it to be used to drive change. VICNISS reports data directly back to health services who are able to compare performance with similar facilities, and also the Department of Health & Human Services who monitor all aspects of health service performance.

Surveillance programs/activities coordinated by VICNISS include:

  • Surgical site infection surveillance (including collection of surgical antibiotic prophylaxis data as a process measure) 
  • Surveillance of infections in intensive care units (ICUs)
  • Surveillance of infections related to invasive device use outside of intensive care units
  • Targeted organism surveillance (e.g. multi-resistant organisms) 
  • Hand hygiene initiative
  • Monitoring vaccination of healthcare workers
  • Monitoring occupational exposures of healthcare workers to blood and body fluid 
  • Surveillance in Residential Aged Care

Surgical site infections                   

Surgical site infections (SSIs) can cause serious acute illness, and increased hospital stays, as well as long-term consequences i.e. emotional and financial stress for patients. Added to these factors are the financial burden on already stretched health budgets of treating these infections and the continuing threat of antimicrobial resistance.

A significant proportion of SSIs are preventable. The first step in prevention is monitoring and feedback of SSI rates. Other more active interventions include using evidence based practices based on improving peri-operative processes, such as antibiotic prophylaxis, diabetic control and normothermia (maintenance of patient temperature).

In Victoria, since VICNISS began coordinating surveillance in 2002 significant reductions have been seen  in monitored surgical site infection rates equivalent to almost a 10% reduction in risk of a serious infection each year1.  

Currently the main surgical procedures monitored are serious heart surgery (cardiac bypass valve replacements), hip and knee replacements, caesarean sections, colorectal surgery and hysterectomies. Some data on infection rates in Victoria can be found at these links

https://www.vicniss.org.au/publications/surveillance-data-for-victoria/

https://www.vicniss.org.au/publications/annual-reports/

In addition to being used by the Coordinating Centre and The Department for reporting, continuous quality improvement and patient safety activities, data are sometimes used by researchers and clinicians who can apply to the Department for access.

1: Worth LJ, Bull AL, Spelman T, Brett J, Richards MJ. Diminishing surgical site infections in Australia: time trends in infection rates, pathogens and antimicrobial resistance using a comprehensive Victorian surveillance program, 2002-2013. Infect Control Hosp Epidemiol. 2015 Apr; 36(4):409-16. 

 

                    Surveillance of infections in intensive care units

Patients are ventilated and have one or more lines inserted into their veins or arteries, usually including a central line. This is a type of catheter which is inserted into a large vein.

Common and serious infections in ICUs include central line-associated bloodstream infections (CLABSIs). These can cause death, long lasting health effects, longer ICU/ hospital stays and obviously distress for patients.    

Rates of these infections in ICUs have been monitored and fed back to executives and clinicians in Victoria since 2003. These rates have fallen significantly over this time, equivalent to a 26% reduction in risk each year.

Data on infection rates in Victorian intensive care units can be found at the following links:

https://www.vicniss.org.au/publications/surveillance-data-for-victoria/

https://www.vicniss.org.au/publications/annual-reports/ 

More recently surveillance has begun on infection related events associated with use of ventilators in ICU. This surveillance is much more recent and no data are yet available.  

Invasive device use outside of intensive care units   

 

Most people admitted to hospital have a catheter inserted into a vein. Additionally, many cancer patients are treated as outpatients and have long term devices implanted for regular venous access, as do patients requiring haemodialysis.

These patients in particular are vulnerable to infections from these long term access devices.        

Hospitals also have the option to monitor infections associated with devices used outside of ICUs, including in haemodialysis outpatients and other settings in the hospital.     

                                                                                                                                                                                                      

 More information including some data and rates of events in haemodialysis units for Victoria can be found in our published annual reports https://www.vicniss.org.au/publications/annual-reports/

 

                               Targeted organism surveillance    

Some bacteria are known to be of particular importance in healthcare settings. These include multidrug resistant organisms such as methicillin resistant Staphylococcus aureus (“golden staph”), vancomycin resistant enterococci (VRE), and more recently the group of organisms known collectively as carbapenamase resistant enterococci (CRE).  

Another organism targeted for surveillance is Clostridium difficile.                      

 

This organism often occurs in patients who have had previous treatment with antibiotics and can cause severe illness and even deaths, and has been associated with a number of outbreaks in hospitals and nursing homes in Europe and North America.  In Victoria we began carrying out surveillance for hospital identified cases of Clostridium difficile infection soon after several cases of severe disease were identified. The level of C.difficile disease in Victoria has never approached levels seen overseas. It is possible this is partly due to a combination of monitoring and attention to infection control and hand hygiene rates.

More information on monitoring of these organisms can be found at the following links:

https://www.vicniss.org.au/publications/annual-reports/

https://www.myhospitals.gov.au/compare-hospitals/healthcare-staphylococcus-aureus-bloodstream/interactive-table

https://www2.health.vic.gov.au/public-health/infectious-diseases/infection-control-guidelines/carbapenemase-producing-enterobacteriaceae-management

 

                                      Hand hygiene initiative

VICNISS coordinates the Victorian hand hygiene program, which is part of the national hand hygiene initiative. Hand hygiene is a general term referring to any action of hand cleansing including washing hands with soap and water or applying a waterless antimicrobial hand rub (e.g. alcohol-based hand rub) to the hands. When hand hygiene is performed correctly, these practices result in a reduction of microorganisms (bacteria, viruses etc.) on the hands.

Hand hygiene is important in helping prevent the spread of healthcare associated infections.

Hand Hygiene Australia helps to ensure all Australian hospitals have a standard approach to hand hygiene including education, monitoring and reporting of results. Hand hygiene practices are monitored by various methods, including observation of health care workers by trained observers who record whether staff have performed correct hand hygiene at required times, for example before changing a wound dressing.

More information about the hand hygiene program is available here:

http://www.hha.org.au/

VICNISS publications regarding hand hygiene in Victoria are listed here:

https://www.vicniss.org.au/publications/peer-reviewed-articles/

 

 Vaccination of healthcare workers    

The National Health and Medical Research Council recommends that healthcare workers who have contact with patients should have documented evidence that they had certain vaccinations, including:

  • Two doses of Measles/Mumps/Rubella(MMR vaccine)

  • A course of Hepatitis B vaccine with post-vaccination serological testing

Staff should also be offered annual influenza vaccinations.

The Victorian Department of Health and Human Services (DHHS) requires that health services maintain a register of staff vaccine preventable disease histories. DHHS also provides free influenza vaccine for public hospital healthcare workers each year. More information about this can be accessed here: https://www2.health.vic.gov.au/public-health/immunisation/adults/vaccination-workplace

VICNISS collate information of documented vaccination levels of healthcare worker immunisations (measles and hepatitis B in smaller hospitals and seasonal influenza in all public hospitals). More information can be found in VICNISS annual reports and publications at the following links:

https://www.vicniss.org.au/publications/peer-reviewed-articles/

https://www.vicniss.org.au/publications/annual-reports/

 

               Occupational exposures of healthcare workers to blood and body fluids

Healthcare workers are at risk of exposure to blood and other body fluids due to the nature of their work. This includes spills and splashes onto the skin or mucous membranes (eyes, mouth etc.) or sharps injuries caused by needles or surgical instruments, and occasionally assaults. Any of these can result in exposure to infectious agents such as bloodborne viruses (Hepatitis, HIV).

The risk of these exposures can be reduced by methods such as use of safety equipment and protective clothing. VICNISS monitors the levels of these exposures and provides reports to hospitals as for other data collections. Currently these have only been monitored in smaller hospitals, however planning is underway to extend monitoring to large hospitals who are already collecting this information.  For more information view our annual reports and publications here: https://www.vicniss.org.au/publications/annual-reports/

https://www.vicniss.org.au/publications/peer-reviewed-articles/

 

Surveillance in Residential Aged Care      

Elderly people are at particular risk for infections. While residential aged care facilities (RACFs) are considered to be residences rather than health care facilities, there are a number of reasons supporting surveillance of infections and related events in this population.

Aged care residents tend to have more frequent hospital visits than younger populations, putting them at risk of acquiring multi-resistant organisms. This can mean that they become colonised (carry the bacteria without any apparent ill effects) or develop an infection. Aged care residents are also more vulnerable to other common infections such as influenza.

       Antimicrobial stewardship (the judicious use of antibiotics and related drugs) is also very important in this group.

Overuse of antibiotics is a big problem in the development of resistance to antibiotics, a problem recognised by the World Health Organisation as a major global threat. Treatment of infections in the elderly sometimes requires specialist knowledge,  for example it is not uncommon for elderly people to have a condition known as “asymptomatic bacteriuria”. This means that they have bacteria in their urine (urine does not normally have bacteria in it), however the bacteria are not causing any symptoms and no treatment is required.  These elderly patients are often found to be on antibiotics unnecessarily, which can cause them other problems (e.g. diarrhoea) and give rise to resistant bacteria.   

VICNISS has been working on surveillance in aged care for a number of years, mainly due to the fact that in Victoria many public health services have residential aged care facilities, and for some smaller health services aged care beds may represent the majority of their beds. This situation is unique to Victoria. You can find out more about residential aged care facilities in Victoria here https://www2.health.vic.gov.au/ageing-and-aged-care/residential-aged-care

                                                 Antimicrobial Stewardship     

VICNISS involvement in aged care began with surveys of public sector residential aged care services (PSRACS) for infections and antibiotic use.                           Which later developed into a joint project with the National Centre for Antimicrobial Stewardship (NCAS) that has now been running for four years as acNAPS.  

For more information about acNAPS click here https://www.naps.org.au/Default.aspx

 

VICNISS together with the residential aged care services team at the Department of Health & Human Services have developed a suite of infection control quality indicators specifically for aged care. Some of these were already collated by VICNISS in acute hospitals and only required minor modifications for application to PSRACS.