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 who monitor all aspects of health service performance.
Surveillance programs/activities coordinated by VICNISS include:
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 since 2013 as Aged Care National Antimicrobial Prescribing Survey (Aged Care NAPS).
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 are co-located with 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: Residential Aged Care Services
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:
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. ↑back to top↑
Surveillance of infections in intensive care units
Patients in intensive care units are very unwell, and usually have devices either attached or inserted (ventilators, catheters etc.) usually including a central line. This is a type of catheter which is inserted into a large vein as part of their care. This makes them particularly prone to infections. Generally, the longer the device is used or inserted the greater the risk of infection. 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.
VICNISS monitors two main types of infections in ICU – CLABSIs and ventilator associated infections. Data collected in order to measure these include:
- Results of laboratory testing (e.g. blood tests)
- Overall number of days for which patients had devices (device-days) inserted/attached.
- The “type” of intensive care unit e.g. adult, paediatric, or neonatal
Rates of CLABSIs 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.
More recently surveillance has begun on infection related events associated with use of ventilators in ICU
Data on infection rates in Victorian intensive care units can be found at the following links:
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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
Targeted organisms 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 Clostridioides 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, surveillance for hospital identified cases of Clostridioides difficile infection commenced soon after several cases of severe disease were identified. To date, the burden of C. difficile disease in Victoria has not approached disease burden seen overseas. This may be due to early institution of monitoring and attention to infection control measures and hand hygiene rates. More information on monitoring of these organisms can be found at the following links:
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VICNISS coordinates the Victorian hand hygiene program, which is part of the National Hand Hygiene Initiative (NHHI). 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.
The National Hand Hygiene Initiative (NHHI) 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
VICNISS publications regarding hand hygiene in Victoria are listed here
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
From 2022 influenza vaccinations will be required for healthcare workers in hospitals and ambulance services. For more information click on the link below:
The Victorian Department of Health (DH) requires that health services maintain a register of staff vaccine preventable disease histories. DH also provides free influenza vaccine for public hospital healthcare workers each year. VICNISS collate annual information on levels of vaccination among healthcare workers for seasonal influenza.
VICNISS also collate information of documented vaccination levels of healthcare worker immunisations for the following vaccine preventable diseases:
- healthcare worker measles immunisation in smaller hospitals
- healthcare worker hepatitis B immunisation in smaller hospitals
More information can be found in VICNISS annual reports and publications at the following links:
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 B, hepatitis C, 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. For more information view our annual reports and publications here:VICNISS annual reportsVICNISS peer reviewed articles